Accreditation Specialist Job Opening

Accreditation Specialist

University Health Care System

• Augusta, Georgia
Category: Health Educator

Responsibilities

The Accreditation Specialist supports the organization by analyzing and interpreting The Joint Commission (TJC) Accreditation and Disease Specific Certification standards, CMS Conditions of Participation (COP), and other regulatory agency standards that apply to hospital-wide practice, as well as assisting in implementing and monitoring systems, policies, and guidelines that will comply with the standards. This position is primarily one of staff support to the Director of Accreditation. In the absence of the Director, Accreditation/Nursing Support Systems will work closely with Senior Administration, Directors, department managers, medical staff and other administrative staff to assure a collaborative approach to problem solving, decision making, and communication to provide quality patient care to patients of all ages. Accountability will be monitored by a peer through direct observation, goal achievement, relevant TJC standard compliance, and is documented in summary fashion in performance appraisals and counselings.

Embraces shared governance nursing organizational principals by serving on nursing councils as participant or leader so that outcome, goals and objectives of nursing are achieved.

The provision of nursing care will be provided in an environment that embraces maximum participation by the staff nurses, the ANA Code of Ethics for Nurses and the ANA Practice Standards at a minimum. May also have specialty-area standards of nursing.

Demonstrates population-specific competencies (e.g. age-specific, cultural sensitivity, patient-centered communication) in performance of role.

Qualifications

Education:
BSN is required. Masters degree in nursing or related area such as MBA, MPH, or MHA is preferred.

Licensure/Certification:

Current licensure as a Registered Nurse in state of Georgia required.

Experience:

Five (5) years experience as professional nurse required. Two of the five years experience as professional nurse must be in line or staff leadership or educator position in which hospital wide perspectives of health care administration are gained.

Knowledge, skills, abilities:

  • Demonstrates knowledge of and ability to implement mechanisms to comply with TJC Comprehensive Accreditation Manual for Hospitals(CAMH) and Comprehensive Accreditation Manual for Home Care (CAMHC) standards, COP, and GA Department of Community Health (DCH) regulations.
  • Demonstrates knowledge of regulatory agency standards, legal limitations and responsibilities of various professions within health care and the ability to communicate these limitations and responsibilities to others.
  • Demonstrates ability to be self directed and innovative in resolving issues involving patient safety.
  • Demonstrates leadership skills to manage people through counseling and teaching, to delegate responsibility, and to hold personnel accountable.
  • Demonstrates ability to develop, establish, and supervise the maintenance of adequate records relating to hospital accreditation.
  • Demonstrates ability to effectively communicate with all levels of personnel, management, physicians, families, and significant others.
  • Demonstrates ability to effectively work under and deal with stress.