Description
Location: Main Campus
Department: ACCREDITATION REGULATORY COMPLIANCE
Schedule: Full Time, 8 HR Day Shift, 7:30 to 16:30

POSITION SUMMARY

Responsible for ongoing accreditation and regulatory compliance for the Health System, including all five inpatient facilities, all outpatient clinics, and the Inpatient Rehabilitation unit. Serves as The Joint Commission Administrator. Coordinates the activities related to continuous Joint Commission survey readiness across the system. Facilitates the completion of the self-assessment survey and its submission to The Joint Commission. Leads teams through TJC surveys, College of American Pathology surveys, and State of Georgia investigations. Leads Partner surveys. Conducts mock surveys at all facilities. Educates and assists various hospital departments in meeting the requirements for insurance company “certification” or “distinction.” Leads teams in preparation for various accreditations and certifications and assists with completion of associated surveys. Provides education to staff and physicians on both Joint Commission standards and CMS Conditions of Participation regulations. Assumes responsibility for various licensures, filing necessary applications, submitting updates, and working with General Counsel and Executive Council to ensure ongoing compliance. Reports directly to the Chief Medical Officer. Accountable to the CMO and the Chief Executive Officer for ongoing compliance and for reporting any potential breaches in regulatory compliance.

KNOWLEDGE, SKILLS & ABILITIES

• Education/Licensure/Certification:
• Degree or license in a Clinical Healthcare field, such as Nursing, Laboratory, Radiology, Respiratory Therapy or a related discipline with a minimum of 5 years acute hospital experience preferred OR,
• Masters degree in Healthcare Administration or Business with at least 5 years healthcare experience preferred.
• Three to five years of experience in hospital regulatory compliance and accreditation preferred.
• Demonstrated ability to work independently and efficiently, and to prioritize tasks.
• High-level critical thinking skills required.
• Computer skills required, including spreadsheet analysis, statistical function analysis, and word processing.
• Excellent communication skills, both written and verbal. Ability to communicate clearly with a diverse population of all ages, variety of cultures, etc.
• Demonstrated ability to understand, apply, and communicate the complex processes related to Accreditation and Regulatory compliance.
• Ability to develop, implement, and interpret the policies and procedures of South Georgia Medical Center, regulatory agencies’ standards and rules, reimbursement rules, etc.
• Ability to communicate to and educate staff at all levels in the organization using a variety of teaching methods in order to facilitate staff understanding of the Accreditation Standards, Elements of Performance, and regulatory requirements.
• Ability to organize both people and processes to achieve efficiency and compliance.
• Ability to work across a multi-hospital system with flexibility, while assuring continued compliance.

Please refer the Job description for details