Accreditation & Certifications Program Manager Job at HaysMed
Overview:
Patient Interaction: No Contact.
Infection Control: Initial and Ongoing training in dealing with infection control. Trainings could include but are not limited to, blood borne pathogens, bodily fluids and bio hazardous materials as it applies to your daily work environment. Qualifications:
The Accreditation and Clinical Certification Manager is responsible to lead activities that prepares and maintains the organization for regulatory accreditation and certification by working in collaboration with all departments to promote excellence in regulatory requirements, organizational goals and operations. The Manager will be responsible to lead regulatory process and develop tools that assist in determining exposure to accreditation/certification risks and identifies opportunities to manage and mitigate those risks. Those tools will include but not limited to mock surveys, department inspections, verge completion on findings from inspections, review/revise/implement policies, ISO audits, restraint audits, assist/develop/validate compliance with corrective action plans and reporting of performance improvement using PDSA (Plan, Do, Study, Act) process. The manager will co-chair Practice council, be a member of the Quality Committee, Patient Leadership, CIP, Stroke, Safety, Joints, CQVA, EDC and will have a supporting role for accreditation and certification for Pawnee Valley.
Position Summary:
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Responsible for the interpretation, implementation, compliance of a variety of regulations and quality data as it relates to the Medicare Conditions of Participation.
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Works closely with hospital leadership, medical staff leadership, providers and quality teams to identify opportunities for performance improvement and detect non-conformance issues.
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Responsible for ISO audit process and reporting of findings to Quality Committee.
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Responsible for providing education and assisting leadership in developing Performance Improvement activities utilizing the storyboard format and the PDCA process.
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Attends meetings as needed to ensure reliable data collection of measures.
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Provides education related to the accreditation and certification process to all levels of staff including leadership, providers, and trainees.
HIPAA: This position will have access to the following Protected Health Information in order to carry out the duties related to their position at Hays Medical Center based on the following criteria:
Primary – required (routine) to do the job;
Secondary – required for the job, but mostly be exception; and
None – no approved access
Description of Information
Primary:
Patient Demographic Information (information used to identify a person): Name, Date of Birth, Address, Race, Marital Status, Religion
Clinical Information (information that describes a patient’s health status): Diagnosis, Reports/Medical Notes, Test Results, Problem List, Procedures, History and Physical
Coding Information (clinical information that is in (alpha) numeric format): ICD-9 Codes, Rev Codes, CPT Codes
Financial Information/Insurance (information related to insurance, billing and payment): Billing Information, Payer Name, Payer ID, Account Balances, Plan Elements Covered, Payment Information, Payment Rates
Primary – required (routine) to do the job;
Secondary – required for the job, but mostly be exception; and
None – no approved access
Description of Information
Primary:
Patient Demographic Information (information used to identify a person): Name, Date of Birth, Address, Race, Marital Status, Religion
Clinical Information (information that describes a patient’s health status): Diagnosis, Reports/Medical Notes, Test Results, Problem List, Procedures, History and Physical
Coding Information (clinical information that is in (alpha) numeric format): ICD-9 Codes, Rev Codes, CPT Codes
Financial Information/Insurance (information related to insurance, billing and payment): Billing Information, Payer Name, Payer ID, Account Balances, Plan Elements Covered, Payment Information, Payment Rates
Patient Interaction: No Contact.
Infection Control: Initial and Ongoing training in dealing with infection control. Trainings could include but are not limited to, blood borne pathogens, bodily fluids and bio hazardous materials as it applies to your daily work environment.
Required:
- Current Kansas Registered Nurse License, Bachelors of Science in Nursing (BSN) required or must have an approved plan to obtain BSN approved by chief nursing officer
knowledge of general nursing and practice - Current registered nurse licensure in the State of Kansas or has work permit from the State Board of Nursing
- BLS certification required or must complete BLS certification with in the first two weeks of employment.
- Complete ISO and accreditation training within two (2) years.
- Additional certification may be required for certain patient care settings or populations.
Preferred:
- MSN
- Strong ability in building excel charts, graphs and formulas.
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