Compliance - Accreditation and Licensure Specialist

Nuclear Care Partners; Grand Junction (CO); On-site; USD 65,000 - 90,000; Full time

Job summary

Nuclear Care Partners is seeking an Accreditation and Licensure Specialist to ensure compliance with state and ACHC standards across multiple locations. The role supports survey readiness, training, and policy updates while collaborating with quality and audit teams.

The perfect candidate will have health care compliance experience, a background in handling external surveys, and a strong ability to educate staff and manage licensure processes efficiently.

Qualifications

• Minimum of 3 years of healthcare compliance or relevant experience.
• Previous experience with external surveys or audit teams, state health department or accreditation surveyors is highly desired.
• Certifications relevant to job duties will be considered.

Responsibilities

• Supports survey preparedness and ensures license and accreditation standards are met across departments.
• Educates staff on clinical documentation requirements and ACHC/state standards.
• Schedules and conducts Mock Surveys and tracks actual survey activities.
• Participates in audits and quality improvement initiatives with a focus on compliance.

Skills

Healthcare compliance

External survey experience

Policy interpretation

Training delivery

Education

Associate or bachelor's degree in related field

Certifications relevant to job duties

Tools

Microsoft Office

Job description

Here at Nuclear Care Partners, great compliance takes a village; ours just happens to be elite. Come build with us!We are looking for an Accreditation and Licensure Specialist!

The Accreditation and Licensure Specialist is responsible for a variety of duties, which may include ensuring the company is following relevant state and federal regulations.The Accreditation and Licensure Specialist reports to the Vice President of Clinical Compliance. This is a non-exempt position. The Accreditation and Licensure Specialist supports and creates positive environments through a personal commitment to the Company’s vision and values.

Responsibilities

• Supports and collaborates with various departments and/or teams in managing survey preparedness, meeting license and accreditation standards.
• Promotes a culture of compliance. Evidenced by ethical actions, work product, communication, education, and completion of duties in alignment with company policies and procedures.
• Understands clinical documentation requirements as it relates to state and ACHC standards; can effectively and efficiently educate various employees. Able to educate on clinical expectations effectively and accurately.
• One of the few primary compliance resources; available to branch leaders and employees when questions or concerns are identified related to survey, state or ACHC standards, quality, policy, or compliance concerns.
• Provides accurate, relevant, and high-quality training on licensure and survey standards and processes to varied clinical and departmental audiences.
• Provides exceptional customer service during any external survey.This includes supporting the branch location. Leaders or other departments during any type of survey (state or ACHC), with minimal supervision. Includes the ability to accurately provide requested policies and assist with answering questions from external surveyors.
• Independently schedules, conducts, documents and reports on all Mock Surveys for ACHC.All locations will have a Mock survey annually.
• Tracks each actual survey, state, complaint, ACHC. The tracker includes meaningful details and SOD, POC.
• Educates, supports and facilitates development of action plans or plans of correction for MOCK surveys, actual state or ACHC surveys.
• Monitors branch’s implementation of their plan of correction and provides guidance.
• Collaborate with Quality and Audit Specialists to identify areas of audit that are elevated risk or appear to be of significant concern related to ACHC accreditation or state standards. Review all audit results.
• Participate and complete various audits competently and consistently based on set standards and expectations.(including admission and quarterly).
• Participate in branch-level quality management meetings, providing input regarding progress on action plans or identifying new areas to focus on. Assists with the development of QI/PI initiatives as needed.
• Reviews and investigates patient complaints and ensures compliance with patients’ rights and policies and works to track, resolve, and report patient grievances.
• Tracks and supports the element of external survey and internal survey in the corporate compliance plan, tracks results and reports to supervisor routinely.
• Participates in providing communication and education, as requested, when policy or procedure is changed or updated due to state or ACHC standards, with supervisor oversight. Demonstrates competence in reading and understanding policies and procedures with skills necessary to clearly explain what the policy means, relates to or the elements and or changes.
• Manages with a high level of competency all state health department licenses and ensures correct and timely application submission, including new states and all renewals, with supervisor oversight.
• Participates in policy and procedure committee.Ensure all policies meet state and ACHC standards as necessary.
• Participate in task forces and committees as requested.
• Perform other duties as assigned.

Qualifications

• Minimum of 3 years of healthcare compliance or relevant experience.
• Previous experience with external surveys or audit teams, state health department or accreditation surveyors, highly desired.
• Certifications relevant to job duties will be considered.
• Associate or bachelor’s degree in related field is preferred