Accreditation Manager, Quality Outcomes - Full Time - Days - Corporate

Job description

Responsible for coordinating ongoing activities to support organizational continual readiness for accreditation and other Centers for Medicare & Medicaid Services (CMS) and state licensure surveys. Acts as point of contact for accreditation related issues. Provides guidance and assists departments to ensure adherence to regulatory requirements.
Principal Accountabilities:
• Establishes and implements systems and processes to ensure continuous adherence to regulatory standards within the assigned medical center.
• Leads and coordinates all Joint Commission Medical Center Accreditation surveys.
• Identifies improvement opportunities and provides support and/or consultative services to quality improvement teams.
• Collaborates with legal and risk management teams to track and trend adverse events, conducts root cause analysis (RCAs) reviews, and ensures the development and timely execution of risk mitigation strategies.
• Participates in the development and implementation of policies, programs, and initiatives in order to improve the overall quality of patient cares services.
• Performs other related duties as assigned.

Required:
• Bachelor's degree in Nursing, Healthcare, or related field.
• 3-5 years of experience in quality improvement, patient safety, accreditation or relevant area.
• Current NJ Registered Nurse Licensure or Clinical Licensure.

Preferred:
• Master's degree in Healthcare, Business Administration, or related field.
• 5 years of clinical experience within an acute care hospital or health system.
• Knowledge of TJC accreditation and CMS regulatory requirements.
• Certified Professional in Healthcare Quality or Accreditation.