Accreditation Regulatory Affairs & Quality Coordinator

Description

Become part of an inclusive organization with over 40,000 teammates, whose mission is to improve the health and well-being of the unique communities we serve.

UNC Health Nash, an affiliated member of the UNC Health system, invites passionate healthcare professionals to join our esteemed team. Governed locally, we proudly serve a diverse patient base, spanning Nash, Edgecombe, Halifax, Wilson Counties, and beyond. With a steadfast commitment to elevating community health through exceptional care, we prioritize excellence, compassion, and innovation, ensuring every individual receives the highest standard of support. Joining our team means becoming an integral part of our dedication to wellness, where we constantly strive to redefine excellence in healthcare through state-of-the-art facilities and pioneering programs. Join us in this transformative journey, where your contributions will make a lasting impact on our community's health and wellbeing.

Summary:

The Coordinator of Accreditation, Regulatory Affairs & Quality Support Services will provide a wide range of project management and quality improvement services. Examples include assisting with survey readiness, data management and quality analysis.

* Coordinate multi-disciplinary team participation in Join Commission, state and federal surveys.

* Oversee all accreditation and regulatory survey activity and direct the responses to these surveys.

* Provide periodic reports to the Executive Team, Medical Executive Committee, Quality Leadership Council, and Boards regarding the organization's regulatory and accreditation status.

* Oversight of the Policy system Boards with respect to state of continuous compliance with applicable standards, laws, and regulations.

* Serve as a member of the Patient Care, Quality and Safety Council.

* Assist as needed with Magnet, Compliance and Risk areas.

* Participate in UNC System Accreditation Committees

* Conduct other job duties as required.

Responsibilities:

1. Researches and provides accreditation and regulatory resources and updates to appropriate departments.

2. Assists with the maintenance of an up-to-date Policy and Procedures Manual for the unit, in proper format, with necessary signature approvals.

3. Serves as a resource person for unit staff regarding computer issues/problems, providing training and assistance, investigating and resolving problems as able, and coordinating outside assistance when needed.

4. Conduct other duties as required.

Other information:

Education Requirements:

* Bachelor's degree in Nursing, Health Care Management, or other Health Related degree.

Preferred Education:

- Master's degree in nursing or other health related field with 5 years of clinical experience, associate degree in nursing 10 years of clinical experience.

Licensure/Certification Requirements:

* Maintains, as applicable, clinical healthcare licensure in North Carolina.

Preferred Certifications & Licensures

* Certification as a Certified Joint Commission Professional (CJCP) through the Joint Commission certification program or Certified Professional Health Care Quality (CPHQ).

Professional Experience Requirements:

* 10 years of experience in Healthcare/Medical - Acute Care (hospital setting)

* 2 years of experience involving work with accreditation, regulatory, and/or certification standards.

Preferred Experience:

* Working knowledge of Joint Commission standards, state and federal regulatory standards.

* Working knowledge of standard QAPI methodologies and practices including Root Cause Analysis (RCA), Failure Mode Effects Analysis (FMEA), TeamSTEPPS, and Lean performance improvement skills.

* Prior experience in the application of QAPI principles to meeting accreditation, regulatory, and/or certification standards.

Additional Specialized Knowledge/Skills:

* Communicate effectively, efficiently, and mindfully with disparate individuals, groups, organizations, and regulatory agencies.

* Conduct effective public presentations.

* Assist with action plans for improvement as related to pertinent standards, laws, and regulations through application of QAPI principles.

* Efficiently use standard electronic word processing, presentation, spreadsheet and database applications.

* Efficiently use available electronic software applications pertinent to accreditation, regulatory, and certification activities.

* Proficiently navigate and audit electronic health records.

Legal Employer: Nash Hospitals

Entity: Nash UNC Health Care

Organization Unit: NGH Quality Support Services

Work Type: Full Time

Standard Hours Per Week: 40.00

Work Assignment Type: Onsite

Work Schedule: Day Job

Location of Job: NASH HC

Exempt From Overtime: Exempt: Yes