Accreditation and Licensure Specialist - Day - Accreditation and Licensure WSRHLocation: WellSpan Health, York, PASchedule: Full TimeHours: M-F DayFull time: 40 hours/weekGeneral SummaryProvides 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, The Joint Commission and DNV accreditation as it applies, in both inpatient and outpatient hospital licensed entities. Independently performs a variety of audits, analysis of the data as well as ensure compliance with regulatory audits. Serves as the back-up for on-site surveys and works with others to facilitate system process and outcome improvements and shared communications with spread of best practices.Duties and Responsibilities
Maintains responsibility for ensuring that all Federal/State/Accreditation Standards related to licensure are being met.
Works closely with the Director to help coordinate survey follow-up activities, including plans of action, monitoring systems, clarifications and challenges.
Schedules and coordinates survey related activities including but not limited to agendas, site visits and educational opportunities.
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 monthly audits of medical records. Reviews records for completeness, accuracy, legibility 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 agency requirements related to accreditation.
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 the Director.
Develops collaborative networking relationships with colleagues responsible for regulatory compliance activities.
Serves as a back-up to the Director in her/his absence.
Serves as a key member on the Environment of Care team for both inpatient and outpatient sites.
QualificationsMinimum Education:
Associates Degree Required
Bachelors Degree Preferred
Work Experience:
1 year Experience in Quality, Patient Safety, Government Regulations, Legal Services, Healthcare and Regulatory Affairs. Preferred.
RN or LPN preferred but not required
Healthcare experience preferred
Regulatory experience a major plus
Previous auditing experience preferred.
Knowledge, Skills, and Abilities:
Demonstrated leadership skills.
Demonstrated knowledge of health care and regulatory affairs.
Must have a global view of the Hospital vision and mission.
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
Flexible spending and health savings accounts
Retirement savings plan
Paid time off (PTO)
Short-term disability
Education assistance
Financial education and support, including DailyPay
Wellness and Wellbeing programs
Caregiver support via Wellthy
Childcare referral service via Wellthy
Apply NowYou’re unique and you belong here.At WellSpan Health, we are committed to treating all applicants fairly and equitably, regardless of their job classification. If you require assistance or accommodation due to a disability, please reach out to us via email atcareers@wellspan.org. We will evaluate requests for accommodation on a case-by-case basis. Please note that we will only respond to inquiries related to reasonable accommodation from this email address. Rest assured, all requests for assistance or accommodation are handled confidentially, allowing applicants to share their needs openly and honestly with us.WellSpan Health is an Equal Opportunity Employer. It is the policy and intention of the System to maintain consistent and equal treatment toward applicants and employees of all job classifications without regard to age, sex, race, color, religion, sexual orientation, gender identity, transgender status, national origin, ancestry, veteran status, disability, or any other legally protected characteristic.