Director of Accreditation and Licensure

Work ShiftDay (United States of America)Job SummaryThe Director of Accreditation & Licensure reports to the Exec. Director Accreditation and Licensure. The Director provides expertise and consultation on The Joint Commission (TJC); Georgia Department of Human Resources (DHR); Center for Medicare and Medicaid Services (CMS); and other regulatory standards and requirements and related processes. This position is responsible for development and provision of strategies to support continuous survey readiness (CSR) activities, link CSR to safety, and compliance across the healthcare system. The Director keeps Senior Leadership informed of Wellstar's survey readiness status as well as new/revised regulatory requirements and the impact on the organization. He/she ensures routine self‑assessment of compliance with various standards/regulations, development of action plans, review and revision of related policies and procedures and submission of Periodic Performance Reviews to the TJC. The Director supports the System during various survey/review activities, i.e., TJC survey, State visits. Ensure timely submission by all of recommendations for improvement and deficiencies identified by outside agencies.Core Responsibilities And Essential FunctionsDevelops strategies to support continuous survey readiness activities across the systemProvides consultation on strategies to support Disease Specific CertificationsIdentifies key metrics to be submitted to system to monitor survey readiness activitiesMonitors and tracks areas of non‑compliance; facilitates barrier removalOversees the process for periodic compliance assessment utilizing V‑SurveyRoutinely reports survey readiness to Sr. LeadershipDevelops strategies to incorporate survey readiness training in leadership onboarding processes and to hardwire skills needed to sustain a state of continuous survey readinessOversees that JC Periodic Performance Reviews are completed as requiredCoordinates mechanism to audit improvements for effectiveness and sustainabilityMonitors and ensures timely submission of recommendations for improvement and deficiencies identified by outside agenciesDirects the Standard Policy and Procedure ProcessDevelops and implements a reliable process for periodic review and revision of policies and proceduresEducates writers on policy and procedure development and formatting, ensuring product reflects current requirementsDirects the approval, implementation and posting processProvides support to site accreditation in all aspects as neededSupports training and ongoing education of System and/or Site Function LeadersDevelops and provides education and mentoring to new employees as requestedSupports the system during various survey preparation/review activitiesDevelops prn pool of staff to support system as neededServes as content expert and consultant to Wellstar Health SystemMonitors current and future state of regulatory requirements and related processesResearch new and/or revised standards; provides guidance to the organizationCollaborates with other organizations; shares experiences and lessons learnedEducates leadership on new and/or revised standards and processes and the potential impact on the organizationDrives continuous survey readiness through leading The Joint Commission Steering CommitteeServes as liaison between system and TJC; communicates with Standards Interpretation Group (SIG) on questions related to standards and communicates responses across systemProvides budget guidance on survey related activitiesOversees Compliance with TJC Leadership StandardsFacilitates leadership review and assessment of compliance with leadership standards and requirementsDevelops and implements action plans to address opportunities for improvement working collaboratively with leadership teamPerforms other duties as assignedComplies with all Wellstar Health System policies, standards of work, and code of conductRequired Minimum EducationBachelor's Degree BS degree in a healthcare related fieldRequired Minimum License(s) And Certification(s)All certifications are required upon hire unless otherwise stated.HCQM - Cert Healthcare Quality Mgt-Preferred within 1 YearRequired Minimum ExperienceMinimum 5 years experience in coordinating regulatory agency survey activities. RequiredRequired Minimum SkillsMust have strong interpersonal skills, be able to multi‑task, be flexible, organization skills to support a multi‑component system travel between components occasional out of town travel for seminars, etc.Join us and discover the support to do more meaningful work—and enjoy a more rewarding life. Connect with the most integrated health system in Georgia, and start a future that gives you more.#J-18808-Ljbffr