Accreditation Program Specialist

Hennepin Healthcare - Minneapolis, MN3.7

Full-timeEstimated: $49,000 - $68,000 a year
We are currently seeking an Accreditation Program Specialist to join our Performance Measurement and Improvement team. This full time role will work days.

This position serves as an accreditation advisor for the hospital and its clinics under general direction and in partnership with the Accreditation Program Manager. This includes matters related to Joint Commission accreditation and CMS regulations including interpretation and education of new and existing standards, assessment of compliance, identification of opportunities for improvement, and actions required to maintain survey readiness.

Provides advice, support and coordination to achieve compliance with Joint Commission standards and CMS regulations
Works in collaboration with the Accreditation Program Manager to advise clinical, operational, and physician leaders of new standards, changing requirements, and critical topics
Provides education to designated groups and/ or functions in the organization including presentations regarding specific topics as requested
Conducts research on standards that require clarification and provides recommendations to the relevant stakeholders.
Supports systems and structures that ensure continual readiness
Designs and implements evaluation processes and tools in collaboration with the accreditation program manager
Conducts tracers and audits and reports findings
Assists with preparation and delivery of manager education, including huddles and other venues
Directs and/or participates in activities designed to improve performance in identified priority areas
Designs, prepares, and distributes meaningful reports
Designs and communicates relevant tracer and audit tools
Collates tracer and audit results
Prepares reports and/or presentations regarding findings and related activities
Serves as a resource for Measures of Success and other metrics that require reporting and analysis
Coordinates survey preparations in collaboration with accreditation manager and organizational leaders
Participates in survey readiness planning
Supports survey coordination requirements including scheduling, logistics, and documentation needs
Assists with required follow-up and formal responses related to survey findings
Ensures that knowledge of standards, regulations, and methods remains current
Maintains expertise and knowledge related to The Joint Commission standards and CMS regulations
Exhibits a working knowledge of other key regulatory standards, including OSHA, HIPAA, etc.
Participates on teams and committees as appropriate to support readiness and improvement efforts
Serves as a member of the Regulatory Steering Committee (RSC) and provides administrative support, including but not limited to taking minutes
Participates in multi-disciplinary performance assessment and improvement teams as requested
Works collaboratively with other leaders, departments and functions to ensure a systems approach to standard interpretation and implementation
Reviews policy drafts for clarity, consistency and compliance prior to them being presented to the Policy Committee
Recommends, develops, designs and implements processes to promote the efficiency and effectiveness of the Policy Committee
Assists employees to draft and finalize policies that will be reviewed by the Policy Committee
Writes and revises policies and procedures to support the hospital policy review and approval process


Minimum Qualifications:
Bachelor’s degree in related healthcare field
Minimum of 3 years hospital and/or ambulatory experience
  • OR-
An approved equivalent combination of education and experience
  • AND/ OR-
If incumbent is a Registered Nurse, possession of a valid license, or a permit to practice, issued by the State of Minnesota Board of Nursing

Knowledge/ Skills/ Abilities:
Knowledge of Joint Commission and CMS regulatory requirements
Analysis, communication, presentation and problem solving skills
Measurement, data gathering, and interpretation experience
Knowledge of patient care standards
Performance improvement principles and methods experience

You've made the right choice in considering Hennepin Healthcare for your employment. We offer a wealth of opportunities for individuals who want to make an impact in our patients' lives. We are dedicated to providing Equal Employment Opportunities to both current and prospective employees. We are driven to connect talented individuals with life-changing career opportunities, enabling you to provide exceptional care without exception. Thank you for considering Hennepin Healthcare as a future employer.

Please Note: Offers of employment from Hennepin Healthcare are conditional and contingent upon successful clearance of all background checks and pre-employment requirements.

Primary Location: MN-Minneapolis-Downtown Campus

Standard Hours/FTE Status: FTE = 1.00 (80 hours per pay period)
Shift Detail: Day
Job Level: Staff
Employee Status: Regular

Eligible for Benefits: Yes
Union/Non Union: Non-Union

Job Posting: Mar-19-2019