Accreditation Coordinator | Team Member | RN | Hospital | Southeastern, U.S.
Galileo Search has a full-time career opportunity for an experienced Accreditation & Quality Coordinator. Our client is a highly regarded not-for-profit acute care hospital system. This high-profile position is partnered with a second Accreditation Coordinator to provide system-wide support.
• Responsible for all aspects of planning and implementation of compliance activities for accreditation and regulatory agency requirements, including The Joint Commission and CMS
• Ensures compliance with all federal and state regulatory and licensing requirements, including aspects of Joint Commission readiness
• Assesses, monitors, and recommends, as appropriate, activities and educational opportunities to maintain compliance with accreditation and/or regulatory standards
• Responsible for documentation and other information as requested by regulatory and accrediting bodies, including, but not limited to, submission of applications
• Identifies plans, educates, and assists in the implementation of change as required by new/evolving standards
• Coordinates site visits, follow-up reports, compliance activities, and historical files
• Focused Standards Assessment (FSA), and action plans
• Responsible for development and implementation of educational activities related to accreditation
•Develops methodologies to support departments in achieving and exceeding continual compliance requirements
• Trains current and new management staff on their role in accreditation and survey activities
• Report to the leadership team announced and/or potential changes in regulatory standards: related implementation plans to assure compliance
• Active RN (Registered Nurse) License
• 5 years clinical acute care hospital experience
• 3 years of current experience in TJC accreditation and compliance to include regulatory survey coordination experience
• Experience in project management, group facilitation, and leadership group presentations
• Must be able to adapt to change and adjust job responsibilities as the organization and outside regulatory agencies mandate
• Knowledge of process improvement methodologies
• Excellent verbal/written communication, interpersonal, and relationship-building skills; will interact with physicians and other key stakeholders
• Must possess a solid understanding of team dynamics
• Self-directed, highly motivated with superb problem-solving abilities
• Proficient in the use of Microsoft Word and Excel programs; advanced computer skills to maintain databases, spreadsheets and develop reporting tools/graphs/control charts
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