We're searching for a Clinical Accreditation Specialist, someone who works well in a fast-paced setting. In this position you will act as a consultant on interpretation of regulatory standards, including The Joint Commission and Centers for Medicare and Medicaid Services (CMS); ensure a constant state of readiness; advises on policy development, educate health care providers on the relevance of standards supporting a culture of safe, high-quality patient care, and contribute leadership and assistance to enterprise-wide initiatives.

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Job Duties & Responsibilities
• Assumes the daily organizational responsibility for quality improvement and compliance for the Arnot Health System.
• Directs all organizational continuous accreditation readiness activities.
• Provides consultative services to all levels of the organization on accreditation/regulatory issues, interpretation of standards and policies, and linkage to clinical and operational processes.
• Develops and implements a continuous readiness plan with scheduled activities designed to educate and engage all levels of staff and providers to sustain high performance per internal and external standards.
• Coordinates formal on-site surveys for The Joint Commission and CMS, acting as primary liaison with the surveyor team, including overseeing and coordinating schedules, activities, and remediation of open issues.
• Manages operational aspects of accreditation applications, ongoing standard assessments, development of corrective action plans for prioritized risks, and design of audits to evaluate the effectiveness of improvements.
• Organizes and delivers education and communication on continuous accreditation standards and readiness at all levels of the organization, including senior leaders, middle managers, physicians, and staff.
• Partners with Safety & Risk Management and Infection Control on sustained compliance with the National Patient Safety Goals and other patient safety standards.
• Partner with quality management and performance improvement to leverage opportunities to sustain compliance with best practices as part of existing improvement teams within operations.
• Ensures documents required by accreditors/regulators are produced and updated and that those responsible for those documents are fulfilling their responsibilities.
• Provides support and expertise to hospital administration's policy and procedure committee with scheduled review and update to appropriate policies and access to all relevant parties.
• Performs other related duties and participates in special projects as assigned.

Skills & Requirements
• RN license required. Bachelor's degree in healthcare related field required; Master's degree preferred.
• Certification is preferred - may include CPHA (Certified Specialist in Healthcare Accreditation), CPHQ (Certified Professional in Healthcare Quality), or other certifications relevant to this field.
• Five (5) years of clinical and/or administrative experience in a healthcare setting, including specific experience related to accreditation and regulatory bodies, such as Joint Commission, CMS, and state licensing agencies required.
• Must have a working knowledge of quality improvement methodologies, tools, and data management skills.
• Leadership and change management skills required. Demonstrated analytical problem-solving skills.
• Effective verbal and written communication skills, including presentation and training capabilities required.
• A general understanding of medical terminology and the Electronic Medical Record for the institution is required.
• Ability to perform assignments independently with minimal supervision is required.
• PC-based computer skills, including Microsoft Office required. Needs to be well versed with software for flow diagrams and mapping lean processes.