Accreditation Coordinator

Professional Lawrence, Kansas


Description

I. JOB SUMMARY
The Accreditation Coordinator has primary responsibility to oversee and coordinate all activities related to The Joint Commission (TJC) accreditation and oversee administrative functions of TJC certifications.  This Coordinator is the primary resource for all TJC standards and elements of performance (EPs).  Leads and participates in committees to support the organization’s commitment to continued TJC accreditation. Specific focus of work is dependent upon organizational needs, timing of survey and may vary throughout each cycle.  As a member of the Clinical Excellence and Value team, this position will have primary responsibility for various outcomes initiatives.  High level of professionalism and time management are necessary to meet performance expectations. Responsible for identifying and supporting performance improvement projects and activities throughout the hospital through education, collaboration, and project oversight.

II. ESSENTIAL JOB RESPONSIBILITIES

  1. Coordinates all activities to maintain accreditation through The Joint Commission (TJC).
  2. Chairs and organizes The Joint Commission Committee.
  3. Researches, develops and maintains knowledge of TJC standards and CMS Conditions of Participation (CoPs) for both hospital and long-term care (LTC) and any changes affiliated with them.
  4. Communicates and educates providers and staff on TJC and CMS CoP changes and updates.
  5. Leads teams and initiatives to address deficiencies and/or changes in TJC and CoP standards.
  6. Identifies opportunities to utilize Operational Excellence in processes relating to TJC standards and CMS CoP.
  7. Coordinates TJC tracer program organizationally.
  8. Oversees administrative functions of TJC disease-specific certifications (main contact for communication from TJC, including reminders, upcoming deadlines, etc).
  9. Actively engages in the culture of quality, safety and high reliability training philosophies for teams to accomplish goals.
  10. Leads, mentors and role models effective meetings to meet goals using collaborative approach.
  11. Performs other duties as assigned.
III. JOB QUALIFICATIONS
Required:        
  • Clinical practice education & license (if applicable) (ex. RN, MT/MLS, etc.)
  • Minimum of 3 years of clinical experience
  • Advanced interpersonal skills including clear and effective communication (both written and verbal) with diverse audiences, strong listening skills and the ability to problem solve and make informed decisions.
Preferred
  • Master’s degree
  • Yellow Belt, Lean Six Sigma or advanced
  • Minimum of 3 years in healthcare process improvement
  • Advanced knowledge of computer spreadsheets and databases
  • Basic knowledge of statistics and statistical methods of analysis.
  • Good organizational skills; ability to prioritize, use good time management and adhere to deadlines as directed.
  • Strong and collaborative team player; works well in a continuous learning environment.      
IV. BEHAVIORAL EXPECTATIONS (common to all positions)
  • Patient 1st – We consider the patient first in everything we do.
  • Better Together – We are part of the LMH team that works together to achieve excellence.
  • Speak Up – We embrace a transparent culture of open, respectful communication where ideas are valued and solutions are created.
  • Innovate! – We actively explore new ideas and approach change with agility and an open mind.
  • Own It/Solve It – We hold ourselves accountable for our actions and we collaborate for solutions.
  • In Joy – We create a workplace that is both fun and meaningful.
At LMH Health we value inclusion and diversity. We are an equal opportunity employer and encourage all to apply.  Employment is decided on the basis of experience and qualifications that meet the business need.

Hours 8:00am-4:30pm Monday through Friday

Email your resume to [email protected]