The University of Kansas Health System Accreditation Coordinator in KANSAS CITY, Kansas
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.
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 mandates
Performs concurrent and closed medical record review audits to assist in determining compliance with accreditation and regulatory requirements
Provide practitioner data for Ongoing Professional Practice Evaluation (OPPE) andFocused Professional Practice Evaluation (FPPE) to Medical Staff Service as requested
Serve as a resource for interpretation of regulatory, accreditation and disease-specific care certification standards (as applicable)
*Must be able to perform the professional, clinical and or technical competencies of the assigned unit or department.
*Note: These statements are intended to describe the essential functions of the job and are not intended to be an exhaustive list of all responsibilities. Skills and duties may vary dependent upon your department or unit. Other duties may be assigned as required.
Bachelor’s Degree in Health Information Management, Nursing, Respiratory Care or Clinical Laboratory Science
Excellent communication, writing, organizational and presentation skills; demonstrates superior oral and written communication and time management skills
Advanced working knowledge of computer spreadsheets and databases Must have strong knowledge base of Microsoft Excel, Word, and prefer experience with data management, ie Microsoft Access
Must be willing to drive to off-site hospital locations
Requisition ID: 2020-23842
Display Department Title: Accreditation and Regulatory Compliance
External Company Name: The University of Kansas Health System
External Company URL: https://careers-kansashealthsystem.icims.com
Street: 4000 Cambridge Street