Southeastern, LA area
Currently seeking a talented and dedicated Accreditation Manager for a great opportunity in the Southeastern, LA area. The ideal candidate will possess 5+ years of current experience working in an acute care hospital and have 3+ years of experience working in an Accreditation Department in a leadership role.
Responsibilities of the Accreditation Manager
Monitor hospital-wide compliance with regulatory and accrediting agencies (i.e. Joint Commission, CMS, QRS, CAP, DHH, hospital licensing) to ensure ongoing survey readiness.
Facilitate and coordinate hospital-wide data collection, measurement, trending and dissemination of information regarding regulatory standards and compliance (i.e. Joint Commission, CMS, QRS, CAP, DHH, hospital licensing).
Inform all management levels regarding current developments and changes in regulatory standards (i.e. Joint Commission, CMS, QRS, CAP, DHH, hospital licensing).
Provides regulatory education to new and existing hospital staff and medical staff to achieve and maintain compliance.
Assists in facilitating quality improvement teams assuring the implementation of strong quality improvement strategies using proven quality methods, tools/techniques.
Initiate, coordinate and support necessary changes or action plans and hospital-wide and department-specific performance improvement projects to support regulatory agency standards.
Oversees and directly supervises the activities and functioning of the PI Coordinator and Peer Review including interviewing, coaching, counseling, orientation, training and evaluation within established guidelines.
Monitors the day-to-day operations of assigned department staff, reacting effectively and efficiently to unplanned circumstances, demands and challenges facing the department to ensure consistent quality of service.
Coordinates other regulatory standards (i.e. Joint Commission, CMS, QRS, CAP, DHH, hospital licensing).initiatives activities as appropriate.
Requirements of the Accreditation Manager
- Bachelor's degree in nursing or health-related science field
- Master’s degree in health-related field preferred
- MUST BE A RN ( will only consider a Non RN if they extremely strong with Accreditation Experience
- Louisiana State RN license or compact license is accepted
- 2-3 years healthcare experience in Accreditation, performance improvement abd JCHAO
- Healthcare experience should be recent and within a clinical setting
- Proficiency with performance improvement models, preferably FOCUS-PDCA Knowledgeable of PI related Joint Commission standards
- Participation in previous Joint Commission survey(s) required. PI related experience required