Accreditation & Licensure Specialist

Description

JOB SUMMARY:  The Accreditation and Licensure Specialist serves as lead in managing and facilitation of the agencies accreditation and licensure work to meet and comply with CARF, Oregon Administrative Rules on  Behavioral Health and Substance Use Program licensing and CCBHC requirements; Elevates leadership on high-risk issues in collaboration with site leadership; Serves the organization to promote operational standardization in alignment with the regulatory standards to educate and update existing and new changes to the regulations for facilities, site leadership, administrative departments, and executive leadership.?

ESSENTIAL FUNCTIONS:

• Elevates to leadership team where opportunities exist to help the programs to improve regulatory knowledge base in CCBHC, CARF and OAR standards; 
• Gains and maintains a solid understanding of CARF, CCBHC and OAR regulations and   changes;
• Assists in support of on-site accreditation and licensure survey support; 

CARF Accreditation:

• Remains current on CARF Behavioral Health Standards
• Communicates changes effectively and efficiently to Program leadership
• Manages CARF QIP and project plan on a regular basis
• Organizes, manages the gathering and storage of proof of compliance with standards in an organized fashion
• Reviews quality management plan in partnership with Quality Team to ensure it meets CARF Standards

CCBHC Licensure:

• Gains and maintains a strong understanding of CCBHC requirements
• Constructs timeline of deliverables and responsible party
• Stays current on CCBHC regulatory changes
• Facilitates updates effectively and efficiently with Leadership

OHA Licensure:

• Maintains BestCare’s calendar of agencies’ program licensure renewals
• Partners with Program Directors in Licensure Renewal process
• Completes OHA Program licensure renewal application, compiling all necessary documents and submitting to OHA 
• Acts as the primary point of contact between OHA Survey office and BestCare Treatment Services
• Notifies leadership and program directors of OAR changes that impact agency 
• Advises internal quality improvement and assurance efforts with CARF scope and understanding to strengthen and/or define the initiatives and responsibilities;
• Assists Program leadership in preparation of site survey to ensure staff and facility are prepared;
• Elevates regulatory changes or updates for presentation at Quality Committee;
• Identifies and evaluates risk factors related to BCTS’s compliance and program integrity obligations; identifies potential areas of compliance vulnerability, and ensures corrective action to reduce or mitigate these risks;
• Other related duties as assigned.

ORGANIZATIONAL RESPONSIBILITIES:

• Models BestCare’s mission, vision, and values, promoting integrity, compassion, and collaboration;
• Supports the organization’s commitment to equity and inclusion, fostering an environment of cultural awareness and respect for all individuals;
• Aligns department goals with organizational strategic initiatives;
• Complies with Code of Conduct, Business Ethics, Employee Handbook, and all relevant policies and OARs;
• Maintains professionalism, confidentiality, and compliance with HIPAA, 42 CFR, and Oregon statutes;
• Attends required meetings, completes required trainings, and ensures certifications and licenses remain current;
• Works independently and collaboratively as a positive member of the BestCare team;
• Performs other organizational duties as assigned.

REQUIRED COMPETENCIES: Must have demonstrated competency or ability to attain competency for each of the following within a reasonable period:

• Solid knowledge and understanding of CARF, OHA, and CCBHC regulations and standards;
• High proficiency in MS Office 365 (Word, Excel, Outlook), EHS platforms, databases, virtual meeting platforms, internet, and ability to learn new or updated software;
• Strong interpersonal and customer service skills;
• Strong communication skills (oral and written) and ability to prepare and present training and presentations;
• Strong organizational skills and attention to detail, accuracy, and follow-through;
• Excellent time management skills with a proven ability to meet deadlines;
• Critical thinking skills
• Ability to maintain strict confidence as required by HIPAA, 42 CFR, and Oregon Statutes;
• Ability to build and maintain positive relationships;
• Ability to function well and use good judgment in a high-paced and at times stressful environment;
• Ability to manage conflict resolution and anger/fear/hostility/violence of others appropriately and effectively;
• Ability to work effectively and respectfully in a diverse, multi-cultural environment;
• Ability to work independently as well as participate as a positive, collaborative team member.

Requirements

QUALIFICATIONS:

EDUCATION AND/OR EXPERIENCE:

• Bachelor's degree in business or a related field, required 
• 5 years of related quality experience in a healthcare environment

LICENSES AND CERTIFICATIONS:

• Project Management Professional (PMP) or ability/commitment to obtain within one year
• Current CARF Surveyor certification preferred or ability/commitment to obtain within 2 years of hire
• Must maintain a valid Oregon Driver License or ability to obtain one upon hire, and be insurable under the organization’s auto liability coverage policy (minimum 21 years of age and with no Type A violations in the past 3 years, or three (3) or more Type B violations)

PREFERRED:

• Experience in a CARF organization 
• Experience in a CCBHC organization