Content Management Systems (CMS), Documentation, Healthcare Administration, Leadership, Mail Processing, Maintain Compliance, Nursing Administration, Patient Safety, Performance Management, Professional License, Quality Assurance, Quality Management, Regulatory Compliance, Strategic Planning, Systems Maintenance, The Joint Commission (TJC)
The position provides leadership and coordination for Continuous Survey Readiness activities, ensuring compliance with accreditation and regulatory standards, including The Joint Commission, CMS Standards of Participation, and patient safety initiatives.
- Develops and maintains data systems using Tracers with AMP to support accreditation functions and participates in quality improvement initiatives.
- Coordinates survey preparedness for announced and unannounced visits, communicates standards updates, and educates departments and staff.
- Serves as Peer Review Contact for relevant organizations and manages official correspondence and reporting related to accreditation outcomes.
- Requires a Bachelor's in Nursing, Healthcare Administration, or related field (Master's preferred), with 5-7 years of accreditation, performance improvement, and quality experience.
- Possesses a professional license, processes documentation for compliance, and develops strategies with system departments to maintain survey readiness.