Clinical Accreditation Coordinator

Job description

Position Title Clinical Accreditation Coordinator Days - Full Time: Bell Hospital: Position Summary / Career Interest: 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 ofsafe 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 mandate...