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Position Summary:
This position is responsible for coordinating activities related to surveys and regulations. The position responds as required to entities such as Centers for Medicare and Medicaid Services (CMS) Kansas Department of Health and Environment (KDHE) Kansas Foundation for Medical Care (KFMC) Leapfrog The Joint Commission (TJC) and other specialty accrediting/certifying bodies as assigned. The position utilizes a variety of tools including on-line sites to respond to requests from regulatory/accrediting/certifying bodies. The position is responsible for maintaining continuous survey readiness and coordinates on-site surveys scheduled and unscheduled.
Key Responsibilities/Essential Functions:
Other duties may be assigned. Regular and reliable attendance is an essential function of the job.
- Coordinates timely data submission to The Joint Commission Leapfrog and other accrediting/regulatory/certifying bodies as required.
- Works with hospital leadership to develop action plans and responses to deficiencies.
- Coordinates and submits responses to external agencies such as TJC KDHE CMS KFMC related to identified deficiencies as required within identified timeframes.
- Assures integrity timeliness and confidentiality of data submission.
- Communicates regular status reports related to regulatory and accrediting bodies to hospital leadership as directed.
- Coordinates on-site surveys.
- Coordinates and implements the hospitals plan for maintaining continual survey readiness.
- Maintains a working knowledge of applicable standards and regulations and acts as a resource to hospital staff and leaders.
- Identifies new/revised standards and regulations and communicates changes to appropriate leadership.
Education and/or Experience
- Bachelor’s degree from an accredited four-year college or university is required.
- Knowledge of The Joint Commission standards and Medicare Conditions of Participation is required.
- Minimum of two years of experience in an acute care setting is required.
- Experience with survey and accreditation processes is preferred.
- Knowledge of analytic techniques and metrics used in analysis of health care data is preferred.
Experience in data analysis and reporting is preferred.
Technical Skills
- Demonstrated proficiency in Microsoft Office (Word, Excel, Access, Powerpoint) is required.
- Possesses the ability to read, analyze and interpret complex documents.
- Possesses the ability to deal with both abstract and concrete concepts.
- Possesses the ability to manage web-based databases.
- Possesses the ability to apply principles of logical or scientific thinking to a wide range of problems.
Certificates, Licenses, Registrations
Certified Professional in Healthcare Quality (CPHQ) preferred.
Physical Requirements
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- The employee must frequently lift and/or move up to 10 pounds.
- Constantly required to be in a stationary position.
- Frequently moves throughout the facility to attend meetings or deliver items.
- Able to tolerate occasional standing on hard and soft surfaces throughout the day.
- Occasionally performs activities that require climbing or balancing, stooping, kneeling, crouching, crawling, and reaching with hands and arms throughout the day.
- Frequently uses hands and fingers to operate such items as a computer terminal and to document information.
- Must be able to communicate verbally, orally, and in written form to a variety of internal and external parties.
- Frequently able to detect and discern both loud and soft sounds such as individual voices and phone calls/paging.
- Frequently able to use all types of vision, such as close vision, distance vision, color vision, peripheral vision, and depth perception, to complete daily tasks.
- Occasionally required to detect unusual odors that could indicate such situations as environmental issues.
Via Christi
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