Accreditation and Licensure Specialist Senior

Duties and Responsibilities

Essential Functions:

• Maintains responsibility for ensuring that all Federal/State/Accreditation Standards related to licensure, certifications, and agreements are being met with a state of continuous survey readiness
• Works closely with the Leadership to help coordinate survey follow-up activities, including plans of action, monitoring systems, clarifications, and challenges.
• Schedules and coordinates survey related and improvement 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. If supporting the WMG, coordinates regulatory and quality improvement standards such as the following areas: Patient Centered Medical Home (PCMH), Immunization guidelines, Vaccines for Children (VFC) Program, Urgent Care Accreditation, Licenses and Permits surrounding Clinical Laboratory Improvement Amendments (CLIA) and other areas as identified.
• Ensures that mock tracer and audit activities take place as appropriate to ensure survey readiness and compliance with regulatory requirements and develops and monitors action plans that are developed to address opportunities identified through the activities.
• Coordinates regulatory and quality improvement standards. If supporting the WMG, coordinates regulatory and quality improvement standards such as the following areas: Patient Centered Medical Home (PCMH), Immunization guidelines, Vaccines for Children (VFC) Program, Urgent Care Accreditation, Licenses and Permits surrounding Clinical Laboratory Improvement Amendments (CLIA) and other areas as identified.
• Keeps abreast of appropriate regulatory, accreditation, and risk management requirements and best practices.
• Develops collaborative networking relationships with colleagues responsible for regulatory compliance activities.
• Knowledgeable about Lean methodologies, International Organization for Standardization (ISO) standards and tools and uses Performance Improvement tools to implement effective process improvements.

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's/ 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.
• Maintains highly confidential information, documentation, and correspondence.