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Organization TypePublic Interest
Years of Experience
Date Last Verified
Corporate Accreditation Officer - Patient Safety Program Duties: Under the direction of the Corporate Director, provides oversight of all accreditation, regulatory compliance and survey activities, including but not limited to Department of Health and Human Services (DHSS), Centers for Medicare and Medicaid Services (CMS), and The Joint Commission (TJC); coordinates responses to the surveys among the TMC operational divisions; leads the implementation of new standards and regulations; guides the development and implementation of necessary and appropriate policies and procedures; directs collaboration and division of responsibilities with appropriate individuals and departments within the corporation; maintains an understanding of patient safety practices and issues. Assesses for and implements risk reduction measures, including assessing and leading activities related to achieving and maintaining ongoing regulatory compliance. In partnership with the Director Quality Outcomes ensures alignment with the Corporate Strategic Plan and Annual Business Priorities: implements the Quality and Patient Safety and Risk Management Plans.
Qualification and Experience
Requirements: Graduate degree in a related healthcare or regulatory field (MSN, MHA, JD, MSL or demonstrated/verified equivalent education. Risk Management Certification, or obtain within 18 months of hire. For employees hired before 10/1/2013, the Risk Management Certification must be obtained by July 31, 2014 to maintain employment. 5+ years experience in healthcare (clinical experience preferred) and 2+ years experience in hospital quality resources/management, risk management, survey/certification, patient safety, compliance, or accreditation. Demonstrated experience with TJC and/or accreditation or licensing survey processes. Strong ability to plan, organize, analyze, and coordinate data/information and activities. Considerable ability to make valid judgments to ensure the integrity of operations and exhibit initiative in the completion of tasks. Excellent verbal and written communication skills including a high degree of professionalism and personal presence. Advanced skills in listening and relationship development with internal stakeholders. Advanced ability to draft, review, and edit substantial written documents.. Knowledge of and comfort with participatory and matrix management approaches which involve clinical department chairpersons, medical staff, administration, department heads (and various levels of management) in addition to external agencies and regulatory bodies. Ability to work independently in a stressful environment while coping with complex situations. Sound judgment sufficient to ensure the integrity of operations and to provide exemplary leadership in the development of teamwork among staff, divisions and medical staff. Considerable knowledge of sample selection, auditing, quality monitoring, and data collection and management., and knowledge of human relations and group dynamics. Considerable skill in facilitating problem solving, motivating individuals and groups, and teaching/coaching others. Ability to establish and maintain effective working relationships within and external to the corporation. Preferred:
Certified Surveyor (CMS or Joint Commission). CPHQ certification. Accreditation Certification. Risk Management Certification. Lean Sig Sigma Black Belt.
Tracking Code: 12468-124
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