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Accreditation Manager - Accreditation

2131 South 17Th Street
Wilmington, NC
Job ID: 3767
Date Posted: Sep 7, 2021

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Job Description

Description

About NHRMC

NHRMC, established in 1967 in Wilmington, NC, is recognized as a preeminent healthcare organization focused on leading our community to outstanding health. We have an 855 bed network of hospitals and multi-specialty physician group practices with more than 200 physicians. With a network of primary, specialty, neighborhood clinics and regional medical centers; you will find our culture is the very definition of best in practice. Join us and find out how many ways NHRMC offers you the chance to focus on what really matters - our patients and community.

About the Job

Location: New Hanover Regional Medical Center

Department: Accreditation

Full Time Equivalent: FTE: 1.000000

Work Type: 64 to 80 Hours Pay Period

Work Schedule: 8HR DAY - Most of shift btwn 7A-3P

Exempt from Overtime: Exempt: Yes

What You'll Do

Summary:

Works under the direction and supervision of the Director of Accreditation. Responsible for managing, coordinating and implementing components of the Accreditation program for the organization systemwide. Responsible for managing and facilitating Det Norkse Veritas DNV and other accreditation/regulatory related workgroups as assigned. Provides assistance, direction, education, and support throughout the organization relating to accreditation/regulatory requirements. Serves as a liaison between the medical center or its affiliated healthcare entities, and accreditation and regulatory agencies. Assists with preparing responses to regulatory and accreditation agencies, such as, Centers for Medicare and Medicaid Services (CMS), Department of Health Service Regulation (DHSR), Det Norkse Veritas (DNV), and other agencies as required. Assumes additional responsibilities as requested or in the absence of the Director of Accreditation. 


Responsibilities:

1.In collaboration with the Director of Accreditation, manages, coordinates and implements, components of the Accreditation sustainability program (such as, Accreditation Talking Points, Accreditation Readiness Team (ART), Medical Record Tracers Team, Leadership Tracer Rounds, Zero Defect Rounds).

2.In collaboration with the Director of Accreditation participates in accreditation and regulatory surveys.

3.In collaboration with the Director of Accreditation, develops responses and action plans accreditation and regulatory compliance issues related to DNV, DHSR, CMS and others as required.

4.Coordinates and facilitates completion of workplans and action plans regarding new regulations or areas identified for improvement.

5.Facilitates DNV preparation by validating standards, conducting rounds, coordinating interviews, reviewing policies and procedures.

6.Participates in survey activities and manages action plans and responding to survey findings under the direction of the Director of Accreditation.

7.Collaborates with leaders and staff to assess compliance with accreditation and regulatory requirements and problem solve areas that require improvements.

8.Maintains ongoing knowledge and awareness of accreditation and regulatory requirements.

9.Develops written education materials about accreditation and regulatory issues, and conducts education as necessary.

10.Is a knowledge resource and provides on-going education to management and staff regarding accreditation and regulatory requirements.

11.Develops, initiates, revises, and maintains organization-wide and department level policies and procedures related to accreditation and regulatory requirements.

12.Establishes positive relationships, communication, and follow-up with Leadership, Medical Staff and all areas of personnel.

Position Requirements

Credentials:
Essential:
* Registered Nurse

Education:
Essential:
* Bachelor of Science

Other information:

Experience: Knowledge and experience of overall hospital operations – regulatory agency exposure and/or related experience preferred. Experience in project management and implementation. Ability to navigate and review an electronic medical record for clinical information. Strong written and verbal communication skills required. Strong organization skills and the ability to multi-task.   

Demonstrates standards of performance (ownership, teamwork, communication, compassion) that support patient satisfaction and principles of service excellence. 

Performs other duties as assigned. 

Individual will possess commensurate combination of education, experience and qualifications. 

Other Information

This position description has been designed to indicate the general nature and level of work performed by employees within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities and qualifications which may be required of the employee assigned to the position. Depending on the location of the job, duties may vary. Receipt of the job description does not imply nor create a promise of employment, nor an employment contract of any kind; my employment with the Company is at will.

  • Member Top 100 Hospitals – In 2016 NHRMC was recognized as a Top 100 Hospital demonstrating significant investment and financial sustainability for the communities we serve. 
  • Newsweek's 2020 list of Best Maternity Care Hospitals - NHRMC Betty H. Cameron Women's & Children's Hospital was named as a Best Maternity Care Hospital by Newsweek. 
  • Forbes America’s Best Large Employers 2018 and 2019Link 
  • Becker’s 150 Top Places to Work in HealthcareLink 
  • Healthgrades Outstanding Patient Experience

Consider a career at NHRMC and become part of this award winning team!

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