Accreditation Specialist

1000 Owensboro Health, Inc.; Owensboro (KY); On-site; USD 40,000 - 65,000; Part time

Job summary

Owensboro Health Regional Hospital is seeking an Accreditation Specialist to support compliance and survey readiness across the Owensboro Health system. You will work with operational leaders to ensure alignment with accreditation standards, regulatory requirements, and internal policies, promoting continuous readiness and quality improvement.

Responsibilities include consulting on accreditation, coordinating licensure/certification activities, training staff, and traveling to off-site locations

Qualifications

• Bachelor's degree or higher in Nursing required upon hire; related field accepted with equivalent experience.
• Minimum of 3 years' relevant accreditation or regulatory experience.
• RN licensure in Kentucky or eligibility required upon hire.

Responsibilities

• Acts as expert consultant for accreditation and regulatory compliance across the organization.
• Coordinates activities related to accreditation, licensure and certification with cross-functional teams.
• Develops staff education materials and trainings for accreditation processes.
• Interprets regulatory standards and communicates changes to stakeholders.
• Travels to off-site locations for accreditation activities as needed.

Skills

Critical thinking

Regulatory compliance

Data interpretation

Project coordination

Communication

Education

Bachelor's degree in Nursing

Bachelor's degree in related field

Job description

Weekend Requirements: As Needed | Work Hours: Variable Hours; Business Need | Status: Part Time - 0.5 FTE (40 hours per pay period) | Entity: Owensboro Health Regional Hospital | Department: Accreditation

Job Summary: Accreditation Specialists serve as key resources supporting compliance and survey readiness across the Owensboro Health system. They work collaboratively with operational leaders to ensure alignment with accreditation standards, regulatory requirements, and internal policies, promoting continuous readiness and quality improvement at all Owensboro Health facilities.

Job Responsibilities: Serves as an expert consultant for staff in one or more of the following areas: accreditation & regulatory compliance, organizational policies, policy management, clinical procedures. Interprets regulatory standards and organizational policies & procedures. Assists with and/or coordinates activities, projects, and operational efforts related to accreditation, licensure, and/or certification with critical organization-wide impact, including participation in regulatory site visits/surveys. This may also include assisting with the development and/or implementation of new or revised processes, policies and/or procedures. Utilizes and/or maintains related databases/information management systems. Responsible for training, updates, security management, and report generation as applicable to assigned database/information management system. Works collaboratively with leadership to plan, facilitate and evaluate multidisciplinary process improvements related to accreditation and regulatory initiatives. Facilitates change process through committee participation as needed. Utilizes standardized methods for improvement efforts, including project coordination. Also utilizes common concepts for statistical analysis, outcomes measurement, quality improvement tools, systems thinking, and operations improvement practices. Interprets and disseminates related data to stakeholders. Reviews and/or develops related content and communicates information to all team members via multiple forms of publication and communication. Develops and implements related staff educational materials as needed. Participates in staff orientation and continuing education as assigned. Required to travel to off-site locations for participation in accreditation & regulatory-related activities.

Skills and Attributes: Requires critical thinking skills and decisive judgment. Works under general supervision. Must be able to work in a stressful environment and take appropriate action. Applies more advanced skills and knowledge in the area of specialization.

Position Requirements

• Work Experience A minimum of 3 years' relevant experience required
• Education Bachelor's degree or higher in Nursing required upon hire OR Bachelor's degree or higher in nursing related field required upon hire
• Additional Education Information A combination of education, training and experience may be considered in lieu of degree.

Licensure/Certification/Registration

• RN - Licensed as a Registered Nurse. Eligible to practice nursing in the State of Kentucky required upon hire
• OR Current licensure in related field required upon hire AND Accreditation/Clinical Program related certification preferred.

Organizational Responsibilities: Supports Owensboro Health’s Mission, Vision, Core Commitments, and business interests. Adheres to all organizational policies and procedures. Executes all tasks and behaves in a manner consistent with a culture of compliance, safety and a high reliability organization.

Additional Job Information: This job description describes the general nature and level of work required by the position. It is not intended to be an all-inclusive list of qualifications, skills, duties, responsibilities or working conditions of the job. Specific duties and responsibilities consistent with the general nature and level of work described may vary by department and additional related duties may be assigned as needed. Some duties listed may not apply to all employees with this job description. The job description is subject to change with or without notice, and Management reserves the right to add, modify or remove any qualification or duty. Nothing in this job description changes the existing at-will employment relationship between the Organization and the employee occupying the position.

Standard ADA Settings

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Physical Demands: (Office Environment) Standing: Occasionally Walking: Occasionally Sitting: Frequently Lifting 0-25 lbs.: Rarely Lifting 25-75 lbs.: Rarely Lifting over 75 lbs.: Rarely Carrying 0-25 lbs.: Rarely Carrying 25-75 lbs.: Rarely Carrying over 75 lbs.: Rarely Pushing/Pulling 0-25 lbs.: Frequently Pushing/Pulling 25-75 lbs.: Rarely Pushing/Pulling over 75 lbs.: Rarely Climbing: Rarely Bending/Stooping: Rarely Kneeling: Rarely Crouching/Crawling: Rarely Reaching: Occasionally Talking: Frequently Hearing: Frequently Repetitive Foot/Leg Movements: Rarely Repetitive Hand/Arm Movements: Frequently Keyboard Data Entry: Frequently Running: Rarely Vision: Depth Perception: Frequently Vision: Distinguish Color: Frequently Vision: Seeing Far: Frequently Vision: Seeing Near: Frequently Hazardous Drug Risk Exposure: Low risk Owensboro Health Core Commitments INTEGRITY - We conduct ourselves with a high level of responsibility, reliability and honesty because we take seriously the trust of our patients and coworkers. RESPECT - We value and accept the unique talents and contributions of every patient, customer and team member in the Owensboro Health community. TEAMWORK - We build a spirit of connectivity and fellowship by striving together to overcome obstacles, surpass goals, celebrate accomplishments and plan the future. INNOVATION - We foster original ideas and creative solutions that improve our daily work and promote the mission of Owensboro Health. SERVICE - We focus on service to patients, customers and team members by anticipating their needs, thoughtfully meeting those needs and continually improving the quality of everything we do. EXCELLENCE - We reach beyond basic expectations to expand our knowledge and awareness, produce exceptional work and provide outstanding service. Owensboro Health is a nonprofit health system with a mission to heal the sick and to improve the health of the communities we serve in Kentucky and Indiana. The system includes Owensboro Health Regional Hospital, nationally recognized for design, architecture and engineering; Owensboro Health Muhlenberg Community Hospital; Owensboro Health Twin Lakes Medical Center; the Owensboro Health Medical Group comprised of over 200 providers at more than 30 locations; three outpatient Healthplex facilities, a certified medical fitness facility, the Healthpark; a surgical weight loss center and program, and the Mitchell Memorial Cancer Center.

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