Summary:

Directs the operation of clinical programs and promotes quality services for the community and patients.

Responsibilities:

• Responsibilities include all aspects of planning and implementation of compliance activities for accreditation and or regulatory agencies requirements, including Joint Commission, State and CMS.
• Coordinates on-site surveys, mock surveys, and consultations.
• Prepares and presents reports on compliance status.
• Coordinates organization sustainability plan for ongoing readiness.
• Develops methodologies and activities to support departments in achieving and exceeding continual compliance requirements.
• Assesses, monitors, and recommends, as appropriate, activities and educational opportunities to maintain compliance with accreditation and/or regulatory standards.
• Educates leaders, staff, medical staff, and other stakeholders on the accreditation process and requirements.
• Provides staff support to committees and work groups charged with accreditation steering and oversight.

Requirements:

• RN required bachelor’s degree preferred
• CPHQ or HACP preferred
• 5 years of clinical acute care hospital experience
• Current compliance experience with standards, requirements, and regulations of The Joint Commission (TJC) on Accreditation of Healthcare Organizations, the Centers for Medicare, and Medicaid Services (CMS), including TJC hospital accreditation requirements, CMS conditions of Participation and State Hospital licensing requirements
• Experience in project management, group facilitation, and leadership group presentations preferred
• Must be able to adapt to change and adjust job responsibilities as the organization and outside regulatory agencies mandate. Must possess a solid understanding of team dynamics
• Excellent verbal and written communication skills and relationship building
• Available to travel within other CHRISTUS Good Shepherd locations

Work Schedule:

5 Days - 8 Hours

Work Type:

Full Time

For more information, please contact Lindsey Duren at [email protected] or 903.276.0394