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Form of workPosition Summary:
The Accreditation and Compliance Manager focuses on regulatory compliance initiatives to support continuous patient readiness, quality and patient safety. The Manager concentrates on oversight of Accreditation and certification processes, including: 1) interpretation and guidance on applicability of standards, regulations and law in consultation with legal counsel as necessary; 2) development, implementation and monitoring of corrective actions; 3) education and communication; and 4) survey operations, including but not limited to The Joint Commission (TJC), Centers for Medicare and Medicaid Services (CMS), and the state Office of Healthcare Quality (OHCQ).
The Accreditation and Compliance Manager is knowledgeable about interpreting and implementing regulatory standards to provide internal support with regulatory processes, including but not limited to: (1) coordinating onsite surveys by external regulatory agencies; (2) developing, implementing and monitoring of action plans, including relevant policy and/or documentation revision and staff/leadership education; (3) coordinating and overseeing a series-wide continuous readiness program; (5) managing ongoing internal efforts at improving overall efficiency and effectiveness of services and functions.
Education:
Bachelor's Degree in health care related field required. Graduation from an accredited school of nursing or related clinical discipline preferred. Master's Degree in health care related field preferred.
Work Experience:
Minimum of 3 years healthcare related experience (experience in regulatory compliance, performance improvement, patient safety or project management preferred).
Knowledge:
Current knowledge of The Joint Commission (TJC) and other regulatory standards, Center for Medicare and Medicaid Services (CMS) Conditions of Participations (CoP) and computerized medical record documentation required preferred.
Skills:
Ability to explain or describe moderately complex clinical and performance information. Ability to define problems, collect data, establish facts, and draw conclusions. Ability to handle multiple, simultaneous tasks effectively and efficiently while maintaining a professional, courteous manner. Ability to anticipate needs, take initiative, and coordinate, prioritize and organize. Current knowledge of electronic medical records.
Proficiency in Microsoft Word, PowerPoint, and Excel.
Johns Hopkins Health System and its affiliates are an Equal Opportunity / Affirmative Action employers. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity and expression, age, national origin, mental or physical disability, genetic information, veteran status, or any other status protected by federal, state, or local law.
Johns Hopkins Health System and its affiliates are drug-free workplace employers.
We are committed to providing a healthy and safe environment for our patients, visitors and staff members. The Johns Hopkins Hospital has a tobacco-free at work policy. Employees must refrain from using any tobacco products during their work shifts - including while at lunch or on breaks, and whether they are on or off campus.
The Accreditation and Compliance Manager focuses on regulatory compliance initiatives to support continuous patient readiness, quality and patient safety. The Manager concentrates on oversight of Accreditation and certification processes, including: 1) interpretation and guidance on applicability of standards, regulations and law in consultation with legal counsel as necessary; 2) development, implementation and monitoring of corrective actions; 3) education and communication; and 4) survey operations, including but not limited to The Joint Commission (TJC), Centers for Medicare and Medicaid Services (CMS), and the state Office of Healthcare Quality (OHCQ).
The Accreditation and Compliance Manager is knowledgeable about interpreting and implementing regulatory standards to provide internal support with regulatory processes, including but not limited to: (1) coordinating onsite surveys by external regulatory agencies; (2) developing, implementing and monitoring of action plans, including relevant policy and/or documentation revision and staff/leadership education; (3) coordinating and overseeing a series-wide continuous readiness program; (5) managing ongoing internal efforts at improving overall efficiency and effectiveness of services and functions.
Education:
Bachelor's Degree in health care related field required. Graduation from an accredited school of nursing or related clinical discipline preferred. Master's Degree in health care related field preferred.
Work Experience:
Minimum of 3 years healthcare related experience (experience in regulatory compliance, performance improvement, patient safety or project management preferred).
Knowledge:
Current knowledge of The Joint Commission (TJC) and other regulatory standards, Center for Medicare and Medicaid Services (CMS) Conditions of Participations (CoP) and computerized medical record documentation required preferred.
Skills:
Ability to explain or describe moderately complex clinical and performance information. Ability to define problems, collect data, establish facts, and draw conclusions. Ability to handle multiple, simultaneous tasks effectively and efficiently while maintaining a professional, courteous manner. Ability to anticipate needs, take initiative, and coordinate, prioritize and organize. Current knowledge of electronic medical records.
Proficiency in Microsoft Word, PowerPoint, and Excel.
Johns Hopkins Health System and its affiliates are an Equal Opportunity / Affirmative Action employers. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity and expression, age, national origin, mental or physical disability, genetic information, veteran status, or any other status protected by federal, state, or local law.
Johns Hopkins Health System and its affiliates are drug-free workplace employers.
We are committed to providing a healthy and safe environment for our patients, visitors and staff members. The Johns Hopkins Hospital has a tobacco-free at work policy. Employees must refrain from using any tobacco products during their work shifts - including while at lunch or on breaks, and whether they are on or off campus.
