Emory Healthcare Accreditation & Certification Program Director in Atlanta, Georgia

Job Title Accreditation & Certification Program Director

Job Requisition ID 73540BR

Operating Unit/Division Emory Healthcare Inc.

Campus Location Emory University Hospital Midtown

Department 442160:EHI Office of Quality

Full/Part Time Full-Time

Regular/Temporary Regular

Work Shift Day

Specific Work Hours 8 AM - 5 PM

PRN Position? No

Job Description Responsible for planning, designing, implementing and coordinating activities to support compliance with the Joint Commission (TJC), CMS, DCH (DHR) and other regulatory standards across all EHC operating units. Maintains current knowledge of CMS, DCH and TJC requirements, provides timely communication to all OU leaders, and serves as main point of contact for DCH, CMS and TJC. Standardizes accreditation processes across all EHC operating units. Identifies and implements best practices for maintaining continued survey readiness (i.e. tracers) and management of survey and post survey activities. Manages Operating Unit on site CMS/DCH surveys, and manages and responds to third party (CMS, DCH, TJC and payer) complaints and quality concerns. Coordinates with OU accreditation leaders to define and implement a system-wide tracer methodology, tracking software, policies and procedures. Provides training and education for EHC staff and leadership. On board and trains new employees. Develops and implements on-boarding training/education plans and modules for new EHC Accreditation staff and leadership. Provides professional development opportunities for OU representatives. Assists Quality & Patient Safety Directors in hiring OU Accreditation Specialist. Provides OU consultant services to assure system survey readiness. Serves as backup to OU specialists. Leads education sessions across OUs in new rules, findings and best practices of regulatory requirements. In collaboration with the OU specialist, schedules and conducts tracers and audits to tracers to ensure system readiness. Coordinates system-level chapter leaders. Shares lessons learned across the system. Provides system summary to leaders of current state of readiness and pending actions. Participates in survey and post survey activities. Co-lead with OU specialist during TJC, CMS and/or DCH surveys. In collaboration with OU specialist and leaders, write responses to findings, perform follow up audits and provide other support to OU as needed.

MINIMUM QUALIFICATIONS:Master's degree from an accredited college or university in nursing, other health-related field or health administration. 5 years of experience in healthcare quality & accreditation and 3 years leadership experience. In lieu of a Master's degree, candidates with 10 years leadership experience in healthcare quality and accreditation may be considered. Must be licensed as a RN in the state of Georgia

Minimum Hourly Rate $ 39.41

Minimum Annual Rate $ 81972.8

Midpoint Hourly Rate $ 54.78

Midpoint Annual Rate $ 113942.4

EEO/AA/Individuals with Disabilities/Veteran Employer