Accreditation Manager, Quality Outcomes - Full Time - Days - Corporate

Atlantic Health System; Newton (NJ); On-site; USD 95,000 - 125,000; Full time

Job summary

Atlantic Health System in Newton, New Jersey, seeks a compliance professional to coordinate activities supporting readiness for CMS and state licensure surveys, and to act as the point of contact for accreditation issues. You will guide departments to regulatory adherence and collaborate with legal and risk management to track adverse events and drive risk mitigation.

The role focuses on coordinating surveys, improving quality, and ensuring ongoing compliance with regulatory standards across the

Qualifications

• Establishes and implements systems to ensure continual regulatory adherence.
• Leads and coordinates Joint Commission Medical Center Accreditation surveys.
• Identifies improvement opportunities for quality improvement teams.
• Collaborates with legal and risk management to track adverse events and perform RCAs.
• Supports policy development to improve patient care quality.
• Performs other duties as assigned.

Responsibilities

• Establishes and implements systems to ensure continual adherence to regulatory standards within the assigned medical center.
• Leads and coordinates all Joint Commission Medical Center Accreditation surveys.
• Identifies improvement opportunities and provides support and/or consultative services to quality improvement teams.
• Collaborates with legal and risk management teams to track and trend adverse events, conducts root cause analysis (RCAs) reviews, and ensures the development and timely execution of risk mitigation strategies.
• Participates in the development and implementation of policies, programs, and initiatives in order to improve the overall quality of patient cares services.
• Performs other related duties as assigned.

Job description

Responsible for coordinating ongoing activities to support organizational continual readiness for accreditation and other Centers for Medicare & Medicaid Services (CMS) and state licensure surveys. Acts as point of contact for accreditation related issues. Provides guidance and assists departments to ensure adherence to regulatory requirements.

Principal Accountabilities:

1. Establishes and implements systems and processes to ensure continuous adherence to regulatory standards within the assigned medical center.
2. Leads and coordinates all Joint Commission Medical Center Accreditation surveys.
3. Identifies improvement opportunities and provides support and/or consultative services to quality improvement teams.
4. Collaborates with legal and risk management teams to track and trend adverse events, conducts root cause analysis (RCAs) reviews, and ensures the development and timely execution of risk mitigation strategies.
5. Participates in the development and implementation of policies, programs, and initiatives in order to improve the overall quality of patient cares services.
6. Performs other related duties as assigned.