Accreditation Manager

Position Summary

Assists the Director of Quality and Accreditation in maintaining a continued state of preparedness for all Joint Commission (JC), Centers for Medicare and Medicaid Services (CMS), and other regulatory and accreditation activities and surveys through active collaboration with all leaders throughout the organization including all offsite locations.

Full Time
Onsite

Key Responsibilities

Essential Functions:

- Integrate Joint Commission (JC) and regulatory requirements into organizational policies, procedures, and protocols.
- Provide education, guidance, and interpretation on JC/regulatory requirements to teams and committees to support continuous readiness.
- Serve as a member of selected teams/committees to represent accreditation readiness.
- Prepare and deliver reports and presentations on key JC topics and activities to relevant forums.
- Coordinate and oversee data collection and submission to JC, CMS, and other accrediting bodies.
- Support Environmental Safety and Emergency Management through knowledge of the Environment of Care (EC) and Life Safety Code (LSC) requirements.
- Develop and maintain continuous patient readiness programs in collaboration with senior leadership to ensure compliance with accreditation standards.
- Organize and conduct patient tracers in inpatient and outpatient areas as part of TJC accreditation requirements.
- Lead and evaluate tracer processes, oversee improvements identified through tracers and surveys.
- The authority to hire, separate, promote, demote, write and administer performance evaluations.
- Other job functions as assigned.

Marginal Functions:

- Perform both essential and marginal job functions in a safe manner as identified by Saint Anthony Hospital and the respective department while adhering to the Hospital's confidentiality norms and standards.
- Assume responsibility for knowing and maintaining established hospital and departmental objectives, policies/procedures.
- Participate in performance activities including problem identification, data collection, solution selection, implementation and evaluation.
- Participate in staff meetings and other in-services, meetings or committees as required.
- Represent the organization by participating in professional organizations, continuing education, outside workshops, seminars, and meetings that relate to Accreditation.

Qualifications:

- Bachelor's degree in Nursing with current Illinois Nursing license.
- Achieves Certified Joint Commission Professional (CJCP) certification within three years and maintains credential as defined by JC.
- Recommended 5 years of nursing experience.
- Fluent in EHR documentation and functionality.
- Knowledge of and experience with JC, Medicare Conditions of Participation and other regulatory requirements including IDPH, OSHA, etc.
- Knowledge of and experience with the development of policies, procedures and protocols.

Compensation: $98K-$156K