General Summary:

The Accreditation Coordinator is primarily responsible for coordinating and responding to initiatives related to the accreditation programs for The Accreditation Commission for Health Care (ACHC), The Joint Commission (TJC), the Centers for Medicare and Medicaid Services (CMS), and other regulatory agencies as appropriate. Under general direction of the Vice President, in collaboration with hospital leadership, and according to established policies and procedures, coordinates and provides leadership in the hospital (in and outpatient services) accreditation and regulatory readiness surveys, activities and improvements, to achieve and sustain compliance with internal and external standards/regulations principles of medical and patient safety.

Knowledge, Skills and Abilities:

• Bachelor’s Degree in Nursing or related clinical field.
• Current Michigan Registered Professional Nurse licensure
• Master’s degree or a Degree in Nursing (BSN) preferred.
• Working knowledge of accreditation standards and regulations with the ability to interpret standards and translate them into organizational policy.
• Ability to analyze compliance/regulatory problems and develop effective solutions for correction.
• Ability to lead and maintain effective working relationships with all levels of employees, medical staff and external vendors.
• Advanced communication and interpersonal skills with all levels of internal and external customers.
• Ability to work independently, make decisions and take appropriate action when concerns arise. Self-motivated.  Ability to work with sensitive and/or confidential information.  Ability to prioritize multiple projects and manage time effectively.

Essential Functions and Responsibilities:

1. Collaborates to identify accreditation/regulatory compliance improvement opportunities/priorities, develop accreditation/regulatory readiness plans and follow through on implementation of plans to ensure accreditation and regulatory requirements are met.
2. Responsibilities include regulatory preparedness, educational planning for survey readiness, technical support, innovative resource development and training for accreditation software.
3. Collaborates with leadership to ensure audits and action plans, recommendations for improvement and updates are provided to regulatory governing bodies.
4. Provides leadership and education and serves as a resource to departments regarding compliance with accreditation/regulatory standards/regulations, process/performance measurements, monitoring and evaluation.
5. Actively leads during the survey process, including the preparation of corrective action plans as required by accrediting/regulatory agencies. Leads the organization accreditation/regulatory readiness committee.
6. Schedules and performs focused, mock and unannounced surveys to assess the organization’s state of readiness for accreditation surveys and regulatory inspections.
7. Assess survey results to identify potential risk. Develops and implements initiatives that improve the overall preparedness of the organization. 
8. Participates in policy development for both compliance and accreditation related issues and promotes quality and safety goals.
9. Defines and tracks necessary reports and metrics reflecting stability as relates to accreditation and regulatory compliance readiness.
10. Performs other duties as assigned. These may include but are not limited to: Maintaining a current knowledge base of department processes, protocols and procedures, pursuing self-directed learning and continuing education opportunities, and participating on committees, task forces, and work groups as determined by management.