About this role
This position is responsible for the facilitation of the accreditation continuous survey readiness plan induding support of on site surveys, scheduled and unscheduled. The position collaborates with departmental leadership to respond to accreditation and survey related inquiries from entities such as The Joint Commission (TJC), Centers for Medicare and Medicaid Services (CMS), State of Florida Agency for Healthcare Administration (AHCA) and other specialty accrediting/certifying bodies as assigned. The position utilizes a variety of tools, including on-line sites, to assist the organization to maintain survey readiness and respond to requests from regulatory/accrediting/certifying bodies.
Responsibilities
Puts into effect the plan for maintaining continuous survey readiness across the organization, which includes but is not limited to: unit/department rounding, dissemination of findings, and education regarding standards compliance.
Maintains a working knowledge of applicable standards and regulations and acts as a resource to hospital staff and leaders.
Communicates identified changes in new/revised standards and regulations to appropriate staff and leadership in a timely manner.
Participates in formal on-site surveys as directed and facilitates annual mock survey activities.
Coordinates timely responses related to accreditation and survey findings to external agencies such as TJC, CMS, AHCA and other accrediting/regulatory/certifyi ng bodies as required.
Collaborates with hospital leadership to develop action plans and responses to deficiencies.
Chairs the Accreditation Readiness Committee and supports annual assessment of compliance as directed.
Communicates regular status reports related to regulatory and accrediting bodies to department leadership and to hospital leadership as directed.
Qualifications
Bachelor's degree required.
Completion of a clinical training program such as Nursing, Pharmacy, Respiratory Care, Medical Technologist, etc. is strongly preferred.
Certified Professional in Healthcare Quality (CPHQ) preferred.
Experience in guiding new facilities through accreditation and survey activities is strongly preferred.
Other facts
About UF Health
University of Florida Health is a world-class academic health center in Florida, encompassing hospitals, physician practices, colleges, centers, institutes, programs and services across northeast and north-central Florida.
UF Health represents the shared vision and commitment to patient care excellence of more than 22,000 employees of the University of Florida Health Science Center and UF Health Shands health care system.
What you'll do
- The Accreditation Specialist is responsible for maintaining continuous survey readiness and facilitating responses to accreditation inquiries. This includes coordinating with leadership, conducting mock surveys, and communicating regulatory changes.
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