Accreditation and Regulatory Consultant

Compliance And Accreditation Specialist

Assists in the evaluation, implementation, monitoring, improvement of compliance with internal and external regulatory requirements, and policies for the organization. Works on a multi-disciplinary team and shares best practices among all areas.

Essential Functions :

• Leads and manages surveys and continuous readiness activities.
• Maintains working knowledge of regulatory and accrediting body standards and rules.
• Prepares and presents regulatory updates to Department as requested.
• Partners with hospital management to guide practice and operations with applicable regulations or standards.
• Acts as a consultant to the unit on all matters related to regulatory and accreditation (TJC, CMS, ODH, OMHAS) surveys.
• Partners with unit on development, implementation and monitoring of action plans.
• Leads or collaborates in work groups to build regulations into operations.

Education Requirement : Bachelor's of Science or work experience in the field equivalent to a bachelors, required. Master's Degree, preferred.

Licensure Requirement : (not specified)

Certifications : Certified Professional in Healthcare Quality, (CPHQ), certification, preferred.

Skills : Demonstrated planning, presentation, and project management skills required. Strong skill in promoting multidisciplinary collaboration.

Experience : 2 years working in a hospital and experience with survey readiness and accreditation related activities.

Physical Requirements : OCCASIONALLY : Biohazard waste, Chemicals / Medications, Climb stairs / ladder, Cold Temperatures, Fume / Gases / Vapors, Hot Temperatures, Loud Noises, Patient Equipment, Pushing / Pulling : 0-25 lbs, Working at Heights

FREQUENTLY : Bend / twist, Driving motor vehicles (work required), Hand use : grasping, gripping, turning, Lifting / Carrying : 11-20 lbs, Reaching above shoulder, Sitting, Squat / kneel, Standing, Walking

CONTINUOUSLY : Audible speech, Color vision, Computer skills, Decision Making, Depth perception, Flexing / extending of neck, Hearing acuity, Interpreting Data, Lifting / Carrying : 0-10 lbs, Peripheral vision, Problem solving, Repetitive hand / arm use, Seeing Far / near

Additional Physical Requirements performed but not listed above : High stressful Environment