Accreditation and Licensure Specialist

Duties and Responsibilities

Essential Functions:

• Maintains responsibility for ensuring that all Federal/State/Accreditation Standards related to licensure are being met.
• Schedules and coordinates survey related activities including but not limited to agendas, site visits and educational opportunities. Works closely with 1-up and other department leaders to help coordinate survey follow-up activities, including plans of action, monitoring systems, clarifications and challenges.
• Educates others in interpretation of standards and assists as needed in planning improvement/compliance. Facilitates the integration of new accreditation, certification and regulatory requirements.
• Manages and assigns all mock tracers for the off-site locations as well as analyzing the data, develops and monitors action plans as well as reports results.
• Performs structured medical record and other audits. Reviews materials for completeness, accuracy, and other indicators as indicated.
• Compiles data for and prepares regularly scheduled or special reports, analyses and statements, after regulatory accreditation or certification surveys
• Analyzes data for significant trends or occurrences. Presents data to the appropriate leadership.
• Evaluates procedures, provides communication and action tools to encourage the team's development of methods to track and ensure sustained improvement over time.
• Develops and oversees the implementation of corrective action plans to address survey findings. Monitors and analyzes all data related to action plans and reports results to leadership.
• Keeps abreast of appropriate regulatory, accreditation, and risk management requirements and best practices.
• Utilizes tracer and environmental rounds findings to initiate improvement. Utilizes Tracer activities as educational opportunity for staff.
• Provides ongoing reports and updates of existing and potential regulatory compliance issues to 1-up and other leaders.

Common Expectations:

• Develops, establishes and implements goals, objectives, and policies and procedures for department/service line/entity operation, which guide and support the provision of the department/service line/entity's services.
• Continuously assesses and improves the department/service line/entity/ performance. Maintains appropriate quality control/assessment programs (if applicable).
• Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in field of expertise.
• Provides outstanding service to all customers; fosters teamwork; and practices fiscal responsibility through improvement and innovation.
• Develops collaborative networking relationships with colleagues involved in regulatory compliance activities. Serves as a back-up to 1-up and other team members in the department.