Accreditation Director - RN Required

20 Northeast Georgia Medical Center, Inc.; Gainesville (FL); On-site; USD 110,000 - 145,000; Full time

Job summary

Northeast Georgia Health System is seeking a Director of Accreditation to lead accreditation readiness across Acute Care Services. This role will collaborate with the Executive Director of Patient Safety & Quality to ensure compliance with DNV and ISO standards and manage a team of accreditation and policy specialists.

Required RN licensure in GA, a Bachelor's degree, and 5+ years in hospital leadership plus accreditation experience. Masters in Healthcare Administration is preferred.

Qualifications

• Current license to practice as an RN in GA.
• Bachelor's Degree.
• Minimum of five (5) years of progressively increasing hospital leadership experience.
• Minimum of 5 years of accreditation experience (DNV and/or ISO) or related healthcare experience.

Responsibilities

• Lead continuous accreditation readiness for System Acute Care Hospitals, CMS, DNV, Georgia Rules and Regs, and ISO.
• Oversee policy and document control processes for the system.
• Collaborate with nursing, operations, Risk, and other departments to drive improvements and readiness.
• Manage the Accreditation team and oversee policy steering committee oversight.
• Ensure staff competency, licensure, certifications, and annual training; coordinate with committees and budget planning.

Skills

Communication

Leadership

Organization

Facilitation

Education

Bachelor's Degree

Master's Healthcare Administration (preferred)

Tools

Policy management

Document control

Job description

Job Category: Executive Leadership Work Shift/Schedule: Varies

Northeast Georgia Health System is rooted in a foundation of improving the health of our communities.

About the Role

Job Summary The Director of Accreditation will work collaboratively with the Executive Director of Patient Safety & Quality to oversee accreditation activities for the Acute Cares Services of Northeast Georgia Medical Center. This position is responsible for implementing a system and culture of continuous readiness for the hospitals and hospital outpatient departments in the system. A primary focus of the position will be supporting clinical and non-clinical departments in continuous compliance with DNV and ISO standards (including control of documented information and audits) and policy management for the system. He/She will support the Executive Director in ensuring the requirements of the Quality Management System (QMS) for System Level Acute Care Services are determined, implemented, and maintained. The Director leads a team of Accreditation Specialists and Policy and Document Specialists that support the Acute Care Services of NGHS.

Minimum Job Qualifications

Licensure or other certifications: Current license to practice as an RN in GA

Educational Requirements: Bachelors Degree.

Minimum Experience: Minimum of five (5) years of progressively experience in a hospital environment, including experience in management.

Minimum of 5 years of Accreditation experience (preferably DNV and/or ISO) or related experience in a healthcare environment.

Preferred Job Qualifications

Preferred Licensure or other certifications: Preferred Educational Requirements: Masters Healthcare Administration, Business Administration or Organization Leadership. Preferred Experience: Experience with policy management.

Job Specific and Unique Knowledge, Skills and Abilities

Strong written and verbal communication skills Strong organizational skills Excellent interpersonal and facilitation skills Knowledge of local, state and national accreditation requirements and survey activities Knowledge of ISO requirements, including control of documented information. Ability to prioritize duties and projects; willing to work flexible hours to meet the needs of the department.

Essential Tasks and Responsibilities

• Leads the continuous readiness and accreditation processes for the System Acute Care Hospitals, specifically CMS, DNV, Georgia Rules and Regs, and ISO.
• Reports and communicates findings, facilitating the completion of action plans, and monitoring.
• Works collaboratively with nursing, operations, Risk, and other departments to proactively identify areas of opportunity, and to implement systems to support improvement and continuous patient and survey readiness.
• Organizes the Accreditation team to support specialty-specific survey and certification activity.
• Manages policy and document control processes for system, including Policy Steering Committee oversight.
• Collaborates with others in the organization to promote consistent and standardized operations related to document control.
• Maintains administrative/strategic oversight for the document control system and oversees current and standardized operations within the system.
• Contributes expertise to hospital/system and medical staff committees, including meeting coordination and facilitation, as requested.
• Communicates and/or escalates unresolved issues, following established policy.
• Reviews and manages contracts pertaining to role functions, as assigned.
• Recognizes and operationalizes work needed to support annual pillars/goals.
• Collaborates with the Executive Director to determine fiscal requirements, preparing budgetary recommendations.
• Ensures that staff are current in competency, assessments, licensure, certifications, and other annual training.
• Completes special projects or assignments, as requested.
• Leads as a lean leader by upholding Quest for Excellence Principles 13A Oversees daily management system deployment for all areas of responsibility 13B Maintains high proficiency in Quest for Excellence behaviors and tools Assesses, coaches, and evaluates staff’s level of performance. Providing daily and periodic guidance, support, and resources to departmental staff to facilitate high quality performance and achievement of organizational goals.

Physical Demands

Weight Lifted: Up to 20 lbs, Occasionally 0-30% of time Weight Carried: Up to 20 lbs, Occasionally 0-30% Vision: Moderate, Frequently 31-65% of time Kneeling/Stooping/Bending: Occasionally 0-30% Standing/Walking: Frequently 31-65% Pushing/Pulling: Occasionally 0-30% Intensity of Work: Occasionally 0-30% Job Requires: Reading, Writing, Reasoning, Talking, Keyboarding, Driving

Working at NGHS means

Working at NGHS means being part of something special: a team invested in you as a person, an employee, and in helping you reach your goals.

Northeast Georgia Health System is an Equal Opportunity Employer and will not tolerate discrimination in employment on the basis of race, color, age, sex, sexual orientation, gender identity or expression, religion, disability, ethnicity, national origin, marital status, protected veteran status, genetic information, or any other legally protected classification or status.

Northeast Georgia Health System (NGHS) is a non-profit on a mission of improving the health of our community in all we do.

Our team cares for more than 1 million people across the region through five hospitals and a variety of outpatient locations.

Learn more at www.nghs.com.