Accreditation and Licensure Specialist

General Summary

Provides direction and leadership to the organization by coordinating activities designed to achieve and maintain compliance with the CMS Conditions of Participation, PA Department of Health, DNV and other accreditations as they apply, for inpatient and outpatient WellSpan licensed entities and locations. Independently performs a variety of audits, analysis of the data as well as ensure compliance with regulatory audits. Serves as a resource for risk management matters for supported areas. Participates in on-site and virtual survey activities and works with others to facilitate system process and outcome improvements and shared communications with spread of best practices.

Duties and Responsibilities

Essential Functions:

• Maintains responsibility for ensuring that all Federal/State/Accreditation Standards related to licensure are being met.


• Schedules and coordinates survey related activities including but not limited to agendas, site visits and educational opportunities. Works closely with 1-up and other department leaders to help coordinate survey follow-up activities, including plans of action, monitoring systems, clarifications and challenges.


• Educates others in interpretation of standards and assists as needed in planning improvement/compliance. Facilitates the integration of new accreditation, certification and regulatory requirements.


• Manages and assigns all mock tracers for the off-site locations as well as analyzing the data, develops and monitors action plans as well as reports results.


• Performs structured medical record and other audits. Reviews materials for completeness, accuracy, and other indicators as indicated.


• Compiles data for and prepares regularly scheduled or special reports, analyses and statements, after regulatory accreditation or certification surveys


• Analyzes data for significant trends or occurrences. Presents data to the appropriate leadership.


• Evaluates procedures, provides communication and action tools to encourage the team’s development of methods to track and ensure sustained improvement over time.


• Develops and oversees the implementation of corrective action plans to address survey findings. Monitors and analyzes all data related to action plans and reports results to leadership.


• Keeps abreast of appropriate regulatory, accreditation, and risk management requirements and best practices.


• Utilizes tracer and environmental rounds findings to initiate improvement. Utilizes Tracer activities as educational opportunity for staff.


• Provides ongoing reports and updates of existing and potential regulatory compliance issues to 1-up and other leaders.

Common Expectations:

• Develops, establishes and implements goals, objectives, and policies and procedures for department/service line/entity operation, which guide and support the provision of the department/service line/entity's services.


• Continuously assesses and improves the department/service line/entity/ performance. Maintains appropriate quality control/assessment programs (if applicable).


• Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in field of expertise.


• Provides outstanding service to all customers; fosters teamwork; and practices fiscal responsibility through improvement and innovation.


• Develops collaborative networking relationships with colleagues involved in regulatory compliance activities. Serves as a back-up to 1-up and other team members in the department.

Qualifications

Minimum Education:

• Associates Degree Required


• Bachelors Degree Preferred

Work Experience:

• 1 year Experience in Quality, Patient Safety, Government Regulations, Legal Services, Healthcare and Regulatory Affairs. Required

Licenses:

• Licensed Registered Nurse Upon Hire Preferred

Knowledge, Skills, and Abilities:

• Demonstrated leadership skills.


• Demonstrated knowledge of health care and regulatory affairs.


• Must have a global view of the health system’s vision, mission, values and strategic goals and plan.


• Needs to be analytical, inquisitive, persistent and detail-minded.


• Just Culture is essential in dealing with possible misconduct.


• Must possess a work ethic that is fair, moral, objective and discreet.


• Project management and computer skills are required.

Benefits Offered:

• Comprehensive health benefits


• Retirement savings plan


• Paid time off (PTO)


• Education assistance


• Financial education and support, including DailyPay


• Expanded Paid Parental Leave

For additional details: Benefits & Incentives | WellSpan Careers (joinwellspan.org)