Job Purpose: This position is responsible for supporting the organization’s mission, vision, and values. Key to this position is providing accountability, coordination, facilitation, consultation and staff education in the requirements of the accreditation standards for MetroWest Medical Center. The position requires a clinical background with working knowledge of the regulatory requirements and metrics of the various accreditation, licensing and reporting agencies, e.g. Joint Commission, DPH, CMS, etc. and project facilitation skills with groups as well as individuals.
Job - Specific Duties and Responsibilities:
1. Technical support for regulatory, accreditation and contractual(payer) compliance, including coordination of Joint Commission
Survey readiness (application, pre and post survey follow up), reporting of various regulated and organization metrics.
2. Compile high level Joint Commission readiness reports on a monthly basis for the purpose of senior level reporting.
3. Reviews Policy and Procedures to assure regulatory compliance.
4. Responsible for coordination of accreditation committee, including assignment of Joint Commission readiness for each team.
5. Staff various standing committees such as policy development and regulatory compliance, to assure support, discussion, documentation,
and general awareness of current, emerging and
other regulatory changes
6. Providing education to responsible clinical/ non clinical and administrative staff regarding the requirements of the
applicable regulations and standards.
7. Facilitating or leading teams to fulfill compliance and required metrics as needed.
8. Liaison to the Medical Staff Department, Medical Records Department, and other various departments to assure ongoing regulatory compliance
10. Assist in the development of a newsletter and other communication methods, including; format, content development, graphics, etc.
11. Assist all clinical and non clinical departments to assure Scope of Service compliance, evaluations and privileging.
12. Implementation of the system to notify clinical/ non-Clinical and administrative staff of current, emerging and ongoing Joint Commission and other regulatory changes.
13. Perform clinical pertinence review function and prepare summary reports for review by Chiefs and Medical Executive Committee.
14. Performs other related duties as assigned or directed.
Organizational Duties and Responsibilities:
Is responsible for creating a respectful environment for our patient and ourselves.
Complies with the MWMC policy on confidentiality of
information regarding patients, families and co-workers.
Adheres to dress code; appearance is neat and clean.
Completes annual educational requirements and
in-service training as required.
Wears identification while on duty.
Reports to work as scheduled and ready to receive
Attends meetings and participates in committees as
Education/Training: Bachelor’s Degree required; nursing and clinical experience preferred
• Knowledge of regulatory, licensing and accreditation requirements
• Knowledge of organizational learning methods
• Knowledge of group facilitation techniques
• Proven interpersonal skills
• Proven written and oral communication skills
• Computer use skills to include: word processing, reports, statistics, graphs using various tools, e.g. Excel, Access, etc.
• At least 3 years experience with accreditation and licensing survey preparation and implementation in a healthcare setting, as guided by Joint Commission, CMS, payer requirements and metrics.