This job was posted by https://idahoworks.gov : For more information,please see: https://idahoworks.gov/jobs/2309563

Under limited direction, plans, organizes and maintains a process toensure organizational compliance with regulatory standards (DNV and CMS)and continuous survey readiness. Serves as an internal consultant forthe interpretation of standards and functional measurement ofcompliance. Develops performance improvement plans with management/staffon an as needed basis. Interprets new regulations for education purposesand implementation efforts.

General responsibilities include working collaboratively to maintaincompliance with accreditation requirements; using data to improvequality of care, including data collection and analysis; coordinatingand facilitating meetings; assisting with ongoing collection ofinformation including deficiencies and opportunities for improvement.

Job Specific and Unique Knowledge, Skills and Abilities:

Excellent verbal and written communication skills; customer serviceskills; ability to provide presentations to diverse audiences.Ability to work collaboratively across department and divisionallines.Well organized and detail orientedAbility to maintain strict confidentiality of protected healthinformation.Ability to prioritize duties and projects; willing to work flexiblehours to meet the needs of the department.Maintains general knowledge of the ISO 9001 requirements.Essential Job Functions:

Serves as an accreditation resource for the organization, to includeMedical Staff and Leadership as requested.

Coordinates the logistics of the accreditation visits, surveyactivities, and follow up (e.g. DNV annual surveys, state/CMS surveys,complaint and validation surveys.

Facilitates reporting of accreditation issues to the appropriate leaderand follows up on investigation and actions taken to resolve the issue.

Facilitates investigation and written response for complaints receivedfrom accreditation agencies.

Participates in analysis, development, implementation, and ongoingmaintenance of action plans and evaluation of strategic quality oraccreditation initiatives.

Communicates changes of standards/rules/requirements of theaccreditation agencies for accreditation/certification purposes to allappropriate parties.

Contributes expertise to hospital/system and medical staff committees,including meeting coordination and facilitation, as requested.

Provides educational opportunities and updates for SMH/CVH leadershipand staff on accreditation standards and requirements, as requested.

Completes updates to the accreditation application to meet vendorrequirements, including notification of new services.

Acts as a liaison between chapter owners and the Quality department inthe creation of data collection tools; assists owner with analysis ofdata and identification of opportunities for improvement.

Facilitates reporting of data and barriers to compliance to the qualityoversight committee (QMC)

Serves as Internal Survey Program Lead and performs internal surveys,based on high risk, high probability to maintain the organization'saccreditation status and compliance with ISO 9001 requirements.

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