**Accreditation Coordinator, Advent Health South Overland Park** **All the benefits and perks you need for you and your family:** + Vision, Medical & Dental Benefits from Day One + Student Loan Repayment Program + Received Magnet® recognition from the American Nurses Credentialing Center in January 2019 **Our promise to you:** Joining AdventHealth is about being part of something bigger. It’s about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that **together** we are even better. **Schedule:** Days, Exempt Location: + **South Overland Park** + 7820 W 165TH ST, Overland Park, 66223 **The community you’ll be caring for:** When you need care, you don’t want to have to travel far. Our dedicated, expert team at AdventHealth South Overland Park, formerly Shawnee Mission Health – Overland Park, provides excellent care to communities of southeastern Johnson County, with 24/7 emergency room services, an advanced imaging center, physical therapy and more. **The role you’ll contribute:** The Accreditation Coordinator is a part of the Quality / Risk Management team and reports to the Manager of Risk and Patient Safety. The Accreditation Coordinator works collaboratively with leadership to ensure Joint Commission standards and CMS Conditions of Participation compliance. Responsible for Joint Commission continuous readiness for the Hospital, Home Care, Behavioral Health, licensed surgery centers and the bariatric hospital. Also serves as a resource for hospital identified programs seeking Joint Commission Certification and other Accreditations. **The value you’ll bring to the team:** **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 of Kansas Risk Management statutes, and Patient Safety Organization (PSO) requirements, as it pertains to patient safety and quality. · Completes accurate and timely collection of data related to regulatory compliance. Qualifications **The expertise and experiences you’ll need to succeed:** **KNOWLEDGE AND SKILLS REQUIRED:** · Microsoft Word and Excel, Windows, typing/word processing · Minimum: 2-5 years of clinical nursing experience **_KNOWLEDGE AND SKILLS PREFERRED:_** · Preferred: 1-2 years of experience in quality management and / or related experience with accreditation coordination **EDUCATION AND EXPERIENCE REQUIRED:** · Bachelor’s in Nursing or healthcare-related field · Minimum: 2-5 years of clinical nursing experience or healthcare-related experience **_EDUCATION AND EXPERIENCE PREFERRED:_** **_·_** **_Bachelor’s of Nursing_** · 1-2 years of experience in quality management and / or related experience with accreditation coordination **LICENSURE, CERTIFICATION OR REGISTRATION REQUIRED:** · Registered Nurse licensed in the state of Kansas or applicable licensure in the state of Kansas **_LICENSURE, CERTIFICATION OR REGISTRATION PREFERRED:_** · CPHQ (Certified Professional in Healthcare Quality) This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances. The salary range reflects the anticipated base pay range for this position. Individual compensation is determined based on skills, experience and other relevant factors within this pay range. The minimums and maximums for each position may vary based on geographical location. **Category:** Quality/Clinical Effectiveness **Organization:** AdventHealth South Overland Park **Schedule:** Full-time **Shift:** 1 - Day **Req ID:** 24044864 We are an equal opportunity employer and do not tolerate discrimination based on race, color, creed, religion, national origin, sex, marital status, age or disability/handicap with respect to recruitment, selection, placement, promotion, wages, benefits and other terms and conditions of employment.