Full-time, exempt position working in the Clinical Systems Improvement Department at Sanford Health.
The Accreditation and Certification Services Coordinator is accountable to oversee assigned entity compliance with Department of Health (DOH) statutory requirements, Center for Medicare and Medicaid (CMS) Conditions of Participation and standards of The Joint Commission (TJC) as applicable to the entity. In addition, Coordinator shall serve in a facilitation role to support and coordinate with those within the organization/entity who have primary responsibility for additional service, department or disease-specific accreditations and certifications. The Coordinator leads committees and task forces formed for the purpose of initial survey compliance and ongoing survey readiness. The role coordinates efforts of additional clinical and support roles to include health and safety, performance improvement, quality, infection preventions and control, compliance and entity clinical services roles to meet DOH, CMS and TJC compliance needs. The Coordinator also works closely with entity executive leaders and directors to ensure operations and designed and implemented to support accreditation and certification compliance standards.
The Accreditation and Certification Services Coordinator reports directly to the Sioux Falls HSD Accreditation and Certification Director. The role has accountability to the entity executive leaders charged with overall accreditation standards compliance. The Coordinator's responsibilities related to mock survey activities are directed by the Sanford Enterprise Accreditation Standards Program Manager.
Responsibilities include: maintaining a current working knowledge of applicable regulations to include state specific DOH statute, CMS Conditions of Participation and TJC standards; communicating new and pending standard interpretations, updates, clarifications and issues of concern to individuals and groups; coordinating monitoring activities to quantitatively and qualitatively assess compliance; preparing discrepancy reports upon which management may act; facilitating process improvement changes to enhance regulatory compliance; facilitating development and implementation of related action plans; and coordinating organization-wide efforts to maintain a constant state of readiness.
To perform the job successfully, an individual should demonstrate the following comptencies: Analytical-Synthesizes complex or diverse information. Critical Thinking and Problem Solving: Works well in group problem solving situations. Project Management: Manages and coordinates project team activities. Written Communication: Demonstrates the abiilty to write cleary and concisely, communicating complex concepts accurately. Verbal Communication and presentation skills - Speaks clearly and persuasively in positive or negative situations. Change Management - Develops workable implementation plans and able to lead teams through a positive change experience and inspire staff to continuously, relentlessly, and obectively reassess and modify workflow process to improve patient care, patient outcomes, and service to all customers. Delegation - Delegates work assignments effectively. Leadership - Effectively influences actions and opinions of others. Quality Management - Looks for ways to improve and promote quality. In addition, the candidate must have the ability to: read, analyze, and interpret regulatory and legal documents, investigate and prepare response inquiries or reported complaints: deal with ambiguity;and be flexible, adaptable, creative, self-directed, and internally motivated. Needs to understand and be committed to the implementation of lean principals in a systematic fashion in appropriate processes. To perform this job successfully, an individual should have knowledge of word processing, spreadsheet and database software, and statistical analysis and display.
Required Skills
Current South Dakota RN license is required or multi-state licensure privileges. The RN functions within the scope and standards of nursing practice as outlined in the South Dakota Nurse Practice Act and Administrative Rules. The Sanford Nursing Practice recognizes the Scope and Standards of Practice (2004) and the Code of Ethics for Nurses with Interpretive Statements (2001) as published by the American Nurses Association as the foundation for nursing care delivery. Certification as a Certified Specialist in Healthcare Accreditation (CSHA) is highly recommended.
Required Experience
Graduate from an American Association of Colleges of nursing or National League for Nursing accredited college of nursing. Master's Degree in nursing preferred. Three to five years experience in regulatory compliance, quality management, and performance improvement or in a management or leadership position in healthcare preferred.
Sanford Health - 9 months ago
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