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Minnesota Visiting Nurse Agency Accreditation Program Specialist in Minneapolis, Minnesota


We are currently seeking anAccreditation Program Specialistto join our PM&I team. This full time role will work days.

This position serves as an accreditation advisor for the hospital and its clinics under general direction and in partnership with the Accreditation Program Manager. This includes matters related to Joint Commission accreditation and CMS regulations including interpretation and education of new and existing standards, assessment of compliance, identification of opportunities for improvement, and actions required to maintain survey readiness.

RESPONSIBILITIES * Provides advice, support and coordination to achieve compliance with Joint Commission standards and CMS regulations o Works in collaboration with the Accreditation Program Manager to advise clinical, operational, and physician leaders of new standards, changing requirements, and critical topics o Provides education to designated groups and/ or functions in the organization including presentations regarding specific topics as requested o Conducts research on standards that require clarification and provides recommendations to the relevant stakeholders. * Supports systems and structures that ensure continual readiness o Designs and implements evaluation processes and tools in collaboration with the accreditation program manager o Conducts tracers and audits and reports findings o Assists with preparation and delivery of manager education, including huddles and other venues o Directs and/or participates in activities designed to improve performance in identified priority areas * Designs, prepares, and distributes meaningful reports o Designs and communicates relevant tracer and audit tools o Collates tracer and audit results o Prepares reports and/or presentations regarding findings and related activities o Serves as a resource for Measures of Success and other metrics that require reporting and analysis * Coordinates survey preparations in collaboration with accreditation manager and organizational leaders o Participates in survey readiness planning o Supports survey coordination requirements including scheduling, logistics, and documentation needs o Assists with required follow-up and formal responses related to survey findings * Ensures that knowledge of standards, regulations, and methods remains current o Maintains expertise and knowledge related to The Joint Commission standards and CMS regulations o Exhibits a working knowledge of other key regulatory standards, including OSHA, HIPAA, etc. * Participates on teams and committees as appropriate to support readiness and improvement efforts o Serves as a member of the Regulatory Steering Committee (RSC) and provides administrative support, including but not limited to taking minutes o Participates in multi-disciplinary performance assessment and improvement teams as requested o Works collaboratively with other leaders, departments and functions to ensure a systems approach to standard interpretation and implementation + Reviews policy drafts for clarity, consistency and compliance prior to them being presented to the Policy Committee + Recommends, develops, designs and implements processes to promote the efficiency and effectiveness of the Policy Committee + Assists employees to draft and finalize policies that will be reviewed by the Policy Committee + Writes and revises policies and procedures to support the hospital policy review and approval process


Minimum Qualifications: * Bachelor’s degree in related healthcare field * Minimum of 3 years hospital and/or ambulatory experience -OR- * An approved equivalent combination of education and experience -AND/ OR- * If incumbent is a Registered Nurse, possession of a valid license, or a permit to practice, issued by the State of Minnesota Board of Nursing Knowledge/ Skills/ Abilities: * Knowledge of Joint Commission and CMS regulatory requirements * Analysis, communication, presentation and problem solving skills * Measurement, data gathering, and interpretation experience * Knowledge of patient care standards * Performance improvement principles and methods experience

Title: Accreditation Program Specialist

Location: MN-Minneapolis-Downtown Campus

Requisition ID: 201193