This position is responsible for accreditation and regulatory compliance preparation activities for UNC Medical Center in Chapel Hill. The Accreditation Manager coordinates multi-disciplinary team participation in Joint Commission, state and federal surveys. The position also provides technical assistance to stakeholders on matters pertaining to the application of Joint Commission standards, CMS regulations and North Carolina Division of Health Service Regulation requirements.
Description of Job Responsibilities:
1. Accreditation Knowledge- Maintains extensive knowledge of the most current accreditation standards and related state and federal regulations. 2. Investigations- Coordinates investigations and responses to complaints received from The Joint Commission. Participates in root cause analysis review of sentinel events. Assists with development and monitoring of corrective action plans. 3. Regulatory Standards- Provides guidance on the interpretation and application of Joint Commission standards, state and federal regulations for the organization's stakeholders. Prepares policies and educational materials required for accreditation and regulatory compliance. 4. Survey Management - Effectively manages Joint commission, CMS and Division of Health Services Regulation (DHSR) surveys. Prepares and coordinates written responses and follow-up. 5. Survey Readiness and Ongoing Compliance- Ensures organizational readiness and ongoing compliance with standards and regulations across UNC Medical Center. Leads activities designed to monitor and improve compliance with standards, including focused tracers, mock surveys and educational sessions.
Bachelor's degree a related field.
Four (4) years of experience in administration or patient care in a hospital setting.
Primary Location: Chapel Hill, North Carolina, United States