JOB SUMMARY:
Work on a team that supports all aspects of The Joint Commission Accreditation Standards and Centers for Medicare and Medicaid Services conditions of participation compliance as well as Department of Health Regulations, Centers of Excellence, Certification and other related external regulatory, accreditation and certification requirements. Independently collaborates and coordinates review of accreditation and regulatory opportunities with Risk Management, Care Transformation, Quality and Safety, and with other quality initiatives and committees. Monitor overall performance metrics related to regulatory and accreditation standards. Responsible for achieving improved performance against standards. Collaborate with lead stakeholders to develop tracers and report to monitor compliance with standards. Lead regulatory readiness monthly meetings. Educate staff regarding regulatory requirements and standards interpretation. Participate in Environmental Rounds to identify and resolve safety issues and noncompliance with regulatory standards. Participate in survey preparation, actual survey and post survey activities. Facilitate creation of corrective action plan with hospital senior leaders. Maintain the collection and analysis of meaningful information for guiding improvement efforts in the AMP tracer auditing database. Eligible for remote work permitted up to 1 day per week.
EDUCATION/
REQUIREMENTS:
Bachelor’s Degree in Health Administration, Nursing, or related Healthcare Professional field. Must be a Certified Professional in Healthcare Quality (CPHQ) or equivalent. 2 years of experience in the following: leading organization accreditation including managing and supporting accreditation by The Joint Commission and Centers for Medicare and Medicaid Services; leading development of system wide projects to improve regulatory activity; creating analytical audit tools, reports, and analyzing data trends to inform performance improvement activities; guiding organizational leaders and creating presentations using Microsoft PowerPoint to educate staff regarding The Joint Commission Accreditation Standards and Centers for Medicare and Medicaid Services, Department of Health Regulations, Centers of Excellence, Certification and other related external regulatory requirements and standards interpretation; and navigating The Joint Commission Connect portal to enter applications, review invoices, review regulatory activity and submit corrective actions plans. Position requires travel to Brown University Health affiliated hospitals at least once per month including: Newport Hospital (20 Powel Ave, Newport, RI 02840); Rhode Island Hospital (593 Eddy St, Providence, RI 02903); The Miriam Hospital (164 Summit Ave, Providence, RI 02906); Bradley Hospital (1011 Veterans Memorial Pkwy, Riverside, RI 02915); Saint Anne's Hospital (795 Middle St, Fall River, MA 02721); and Morton Hospital (88 Washington St, Taunton, MA 02780). Salary ranges from $95,264-$157,206.40, depending on qualifications and experience. Please apply via jobs.brownhealth.org, reference #438524.
Pay Range:
$95,264.00-$157,206.40EEO Statement:
Brown University Health is committed to providing equal employment opportunities and maintaining a work environment free from all forms of unlawful discrimination and harassment.
Location:
Saint Annes Hospital - 795 Middle Street Fall River, Massachusetts 02721Work Type:
M-F 8:00am-5:00pmWork Shift:
DayDaily Hours:
8 hoursDriving Required:
NoSkills Required
- Bachelor's degree in Health Administration, Nursing, or related healthcare field.
- Certified Professional in Healthcare Quality (CPHQ) or equivalent.
- Minimum 2 years leading organizational accreditation, including managing/supporting The Joint Commission and CMS accreditation processes.
- Minimum 2 years leading system-wide projects to improve regulatory and accreditation activity.
- Minimum 2 years creating analytical audit tools and reports, and analyzing data trends to inform performance improvement.
- Minimum 2 years guiding organizational leaders and creating presentations (Microsoft PowerPoint) on accreditation standards and regulatory interpretation.
- Experience navigating The Joint Commission Connect portal to enter applications, review invoices, track regulatory activity, and submit corrective action plans.
- Ability to travel to affiliated hospitals at least once per month (listed hospital locations).
