Job Description

Regulatory and Accreditation Coordinator
Location
St. Dominic Hospital
Department
QUALITY AND PERFORMANCE - 7700
Employment Type:
Full Time 80
Shift:
Day
Other Shift Details:
Job Code:
14429

Job Summary:

Ensures that the hospital maintains compliance and readiness for accreditation, certification, and regulatory inspections. Ensures that the hospital policies, guidelines, and procedures are maintained and current. Serves as Emergency Management Coordinator for the hospital. Serves on hospital committees and forums as requested. Reports to the Executive Vice President of Medical Affairs and Quality.

Job Requirements:

Minimum Education- Master's Degree required.

Minimum Work Experience- At least five years experience in leading Joint Commission survey activities

Essential Functions:

Directs and monitors organizational adherence to accreditation, certification, and regulatory requirements. Directs activities associated with pre-survey readiness and post-survey follow up for accreditation, certification, and regulatory surveys within the hospital. Provides the hospital with consultation, education, and guidance as it relates to maintaining compliance with accreditation, certification, and regulatory requirements. Keeps organization leaders abreast of new and changed requirements for accreditation, certification, and regulatory compliance. Develops and implements strategies to maintain accreditation, certification, and regulatory compliance.Directs and monitors activities associated with auditing, reporting, and achieving compliance to accreditation, certification, and regulatory requirements including root cause analyses, complaint responses, patient safety initiatives, and etc.Provides oversight for policy, guideline, and procedure development and approval.Develops and maintains a hospital-wide format and methodology for development and distribution of policies, guidelines, and procedures.Directs the development, consolidation, maintenance, and approval processes for hospital policies, guidelines, and procedures. Provides the hospital with consultation, education, and guidance as it relates to policies, guidelines, and procedures.Directs activities associated with emergency management to include mitigation, preparedness, response, and recovery. Collaborates with local, State, and Federal emergency management agencies. Provides the hospital with planning and education in emergency management activities. Services in the Hospital Incident Command System.

Application Instructions

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