Clinical Accreditation Coordinator

Accreditation Coordinator Bell Hospital

The Accreditation Coordinator leads and / or assists the Manager in system-wide activities to evaluate and improve adherence to The Joint Commission (TJC) accreditation standards and CMS Conditions of Participation (CoPs), including ongoing readiness for accreditation surveys as well as regulatory complaint investigations. The mitigation of regulatory compliance risk will at all times focus on assuring the delivery of safe patient care.

Responsibilities and Essential Job Functions

• Assist in assuring accuracy and timeliness in submission to reporting centers (i.e. Sterling Readiness Rounds)
• Collects, analyzes and reports data in support of continuous readiness activities
• Conducts patient and system tracers in patient care areas through observation of practice
• Disseminates the results of audits and surveillance as needed and as data is available
• Interpretation of relevance of standards in relation to hospital and clinic policies and practice
• Maintain databases and sources of information for quality initiatives, accreditation efforts, and regulatory mandates
• Performs concurrent and closed medical record review audits to assist in determining compliance with accreditation and regulatory requirements
• Provide practitioner data for Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE) to Medical Staff Service as requested
• Serve as a resource for interpretation of regulatory, accreditation and disease-specific care certification standards (as applicable)
• Must be able to perform the professional, clinical and or technical competencies of the assigned unit or department.
• These statements are intended to describe the essential functions of the job and are not intended to be an exhaustive list of all responsibilities. Skills and duties may vary dependent upon your department or unit. Other duties may be assigned as required.

Required Education and Experience

Preferred Education and Experience

Knowledge Requirements