Accreditation Specialist

Albany Medical Center; City of Albany (NY); On-site; USD 95,000 - 147,000; Full time

Job summary

Albany Med Health System is seeking an Accreditation Specialist in Quality Management to lead chart reviews, data audits, and compliance activities with CMS, NYS DOH, and other regulators. You will coordinate survey preparation, educate staff on standards, and support departments in improving Leapfrog measures.

The role requires independent work, strong data analytics, and effective communication as you ensure adherence to accrediting bodies and protect patient safety.

Qualifications

• Experience with chart review and data extraction for accreditation programs.
• Knowledge of CMS, NYS DOH, DNV and Leapfrog requirements.
• Ability to access and analyze data to support regulatory compliance.

Responsibilities

• Independently gathers and summarizes information for reporting and other purposes.
• Pursues continued education of standards, regulations, and requirements by accrediting bodies.
• Educates self and uses audit systems proficiently.
• Works with leadership to resolve questions and issues.
• Meets accreditation and CMS regulations for chart review.
• Uses data analytics to enter, organize, and interpret data.

Skills

Chart review

Data analytics

Audit systems

Regulatory compliance

Interdepartmental coordination

Tools

Audit software

Databases

Job description

Department/Unit: Quality Management

Work Shift: Day (United States of America)

Salary Range: $94,957.00 - $147,183.00

The Accreditation Specialist is responsible for chart review/abstraction and closed record review as well as audit activity to promote patient safety and continuous compliance with accrediting organizations and CMS. This role will be responsible for assisting the department or division head in overall administration of work unit/department and requires a demonstrated high degree of knowledge, competence, and administrative support skills, and the ability to operate with considerable independence.

Job Functions

• Independently gathers and summarizes information for reporting and other purposes.
• Pursues continued education of standards, regulations, and requirements as put forth by the DNV, CMS, New York State, DOH, OSHA, and other regulatory bodies.
• Educates self and has the ability to use the audit system proficiently.
• Works with departmental leadership and other applicable stakeholders to resolve questions and issues.
• Independently gathers and summarizes information for reporting and other purposes.
• Meets all accreditation and CMS regulations for chart review.
• Ability to use data analytics and databases to enter raw data, organize data, run reports, and help make interpretation of the data.
• Uses proper protocols to access, view, and distribute personal health information necessary to do the job.
• Performs chart audits on current inpatients and can perform tracers in patient care areas.
• Coordinates and supports logistics during survey preparation, survey activity, and deficiency corrective action.
• Copies, faxes and scans as needed to communicate for the department.
• Establishes, maintains, and revises record keeping systems.
• Meets all accreditation/CMS regulations for chart review protocols and assist department to do the same.
• Greets, identifies and directs internal/external staff/inquiries in person or by telephone, and follows up as needed. Provides information and identifies solutions to address issues that arise and refers to appropriate person/authority as needed.
• Available to all personnel who ask questions/make requests in a timely manner.
• Assists users to obtain access to and training for the audit system.
• Works with various programmatic groups to develop and implement strategies to improve Leapfrog measures.
• Leads Accreditation presentations and other Accreditation Department led meetings, as necessary.
• Proactively identifies and examines opportunities for improvement within the organization.
• Leads departmental Environment of Care Rounds through appropriate patient care areas including hospital and clinical settings.
• Escalates barriers identified if unable to help mitigate via chain of command within the department in a timely manner.
• Assists with the oversight of the department intranet website content.
• Additional duties as assigned.

Thank you for your interest in Albany Med Health System!

Albany Med Health System is an equal opportunity employer.

This role may require access to information considered sensitive to Albany Med Health System, its patients, affiliates, and partners, including but not limited to HIPAA Protected Health Information and other information regulated by Federal and New York State statutes. Workforce members are expected to ensure that:

Access to information is based on a "need to know" and is the minimum necessary to properly perform assigned duties. Use or disclosure shall not exceed the minimum amount of information needed to accomplish an intended purpose. Reasonable efforts, consistent with Albany Med Health System policies and standards, shall be made to ensure that information is adequately protected from unauthorized access and modification.