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Accreditation Coordinator RN

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Job Details
Job Order Number
Company Name
Physical Address

Shawnee, KS 66217
Job Description


Accreditation Coordinator AdventHealth Shawnee Mission

Location Address: 9100 W. 74th Street, Shawnee Mission, KS 66204

Top Reasons To Work At AdventHealth Shawnee Mission

  • Providing faith-based, whole person care to Kansas City since 1962
  • Excellent health benefits, an onsite child care center and fitness facility
  • Tuition reimbursement to support continuing education
  • Employee Referral Program
  • Largest health care provider in Johnson County with three campuses

Work Hours/Shift:

Full Time, Days

You Will Be Responsible For:

Department Core Competencies

  • Utilizes the Performance Improvement Model

  • Utilizes excellent interpersonal skills to deal with challenging situations while maintaining strong supportive relationships.

  • Readily available for questions; handles requests in a courteous and respectful manner.

  • Communicates effectively, both written and verbally.

  • Demonstrates a proactive attitude and seeks to remedy situations before mistakes are made or corrects errors when found; takes responsibility for the overall quality image of the department.

  • Ensures accuracy of data collection and submission; validates integrity of data collected.

  • Develops data reports for projects, committees, hospital departments, medical staff departments, as designated.

  • Knowledge of and utilizes statistical approaches, measurement techniques, including benchmark and comparative data to develop quality reports.

  • Collects, aggregates, analyzes, summarizes and reports quality data for hospital organizational performance and physician performance data as indicates.

  • Participates in hospital-wide outcomes and quality improvement initiatives/ performance improvement teams.

  • Assists in efforts to improve and streamline the process and workflow of the department.

  • Demonstrates the ability to set appropriate priorities.

  • Recognizes how absence impacts the functioning of the healthcare team and strives to minimize this effect.

  • When requested, is willing to adjust personal schedule in order to complete workload when necessary

  • Attends educational offerings as needed to promote continuous learning and support to department

Position Core Competencies

  • Responsible for staying current on CMS Conditions of Participation (CoP) and Joint Commission standards for all levels of care.

  • Responsible for Joint Commission Accreditation/CMS CoP Compliance

  • Ensures continuous survey readiness/compliance with accreditation standards.

  • Conducts or coordinates MOCK surveys, tracers, rounding, compliance audits,

  • Conducts and abstracts chart audits of documentation e.g. clinical pertinence for the medical staff, open records reviews, critical test results, etc.

  • Conduct Focused Standard Assessment for accredited programs

  • Communicates with and educates associates and medical staff on Joint Commission standards

  • Facilitates and coordinates changes necessary to remain compliant-“ever ready activities”

  • Responsible for on-site survey activities (preparation, planning, coordinating, etc.)

  • Serves as a liaison between AHSM’s accredited programs and the Joint Commission

  • Communicates and facilitates necessary changes in order to remain continuously compliant with accreditation standards.

  • Collaborates with other hospital leaders in developing, monitoring, reporting and analyzing accreditation efforts.

  • Proactively seeks opportunities/mechanisms aimed at continually improving patient care, processes and compliance.

  • Recommends and facilitates change to improve based on identified risks.

  • Facilitates the creation of an effective action plan in response to identified issues.

  • Responsible for follow through and oversight for completion and actions plans relating to identified issues, including follow up measures of effectiveness.

  • Working knowledge

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