Specialist, Licensing & Accreditation

Mary Washington Healthcare; Fredericksburg (VA); On-site; USD 52,000 - 77,000; Full time

Job summary

Mary Washington Healthcare in Fredericksburg, VA seeks a regulatory compliance professional to plan and coordinate activities ensuring JCAHO, CMS, and state licensure readiness. This role supports programs to improve clinical and operational performance related to licensing and accreditation.

The position collaborates with leadership, coordinates survey activities, and stays current on accreditation standards.

Qualifications

• Bachelor’s degree required.
• RN is preferred.
• Experience with TJC Accreditation Standards, State Licensure, and CMS Conditions of Participation required.
• Strong analytical skills required.
• Effective communication skills required.
• Ability to work effectively with all levels of the organization.
• Clinical experience is preferred.

Responsibilities

• Coordinates activities to maintain ongoing compliance with JCAHO accreditation standards.
• Coordinates activities to maintain ongoing compliance with State Licensure and CMS Conditions of Participation.
• Serve as co-leader for the Regulatory Readiness Team.
• Escort External Surveyors during site surveys.
• Research and stay current in accreditation/licensing fields.
• Participate in educational programs supporting licensing standards.
• Promote and improve processes related to licensing/accreditation.
• Maintain professional competency through organizations and continuing education.
• Performs other related duties as assigned.

Skills

Analytical skills

Communication

Teamwork

Education

Bachelor’s Degree

Job description

Start the day excited to make a difference…end the day knowing you did. Come join our team.

Job Summary:

This position participates in the planning and coordination of activities designed to maintain ongoing compliance with JCAHO Standards, CMS Conditions of Participation, and State Licensure Requirements. This position assists in keeping the organization in an ongoing state of readiness for all healthcare licensing and accreditation surveys. This position will also assist in the implementation of programs and services to improve the clinical and operational performance of Mary Washington Healthcare as they relate to licensing and accreditation. This individual will support the mission, vision, values and strategic initiatives of Mary Washington Healthcare and must demonstrate a commitment to quality service to patients, physicians, the community, and co-workers.

Essential Functions & Responsibilities:

• Coordinates activities designed to maintain on-going compliance with all JCAHO accreditation standards.
• Coordinates activities designed to maintain on-going compliance with all State Licensure requirements and Medicare Conditions of Participation.
• Serve as co-leader for the Regulatory Readiness Team
• Serves as an escort for External Surveyors (JCAHO, State, and CMS) when they are surveying our facilities.
• Obtains literature and completes research necessary to remain current in the field of accreditation and licensing.
• Participates in educational and networking programs that support efforts to comply with JCAHO and licensing standards.
• Actively promotes and improves processes and educates appropriately as they relate to licensing and accreditation.
• Maintains professional competency and career growth through participation in professional organizations and continuing education activities.
• Performs other related duties as assigned or requested.

Qualifications:

• Bachelor’s Degree is required.
• RN is preferred.
• Previous experience with TJC Accreditation Standards, State Licensure Requirements, and CMS Conditions of Participation is required.
• Strong analytical skills are required.
• Effective communication skills are required.
• Must demonstrate the ability to work effectively with all levels of the organization.
• Clinical experience is preferred.

MWHC will not discriminate in its employment practices due to an applicant's race, color, religion, sex, sexual orientation, gender identity, national origin, and veteran or disability status (EOE). We are also committed to equitable and transparent compensation practices and comply with all applicable pay transparency and pay equity laws.

Required Physical Requirements:

Constant (67-100% of workday) sitting and use of arms and hands; occasional (0-33% of workday) standing, walking, bending, squatting; ability to lift, push, and pull up to 10 lbs.; auditory and visual skills.

Mental Requirements:

• Possesses critical thinking and analytical skills.
• Ability to multi-task.
• Ability to communicate effectively and collaborate with a multi-disciplinary team.

Environmental Requirements and Exposure Hazards:

Potential risk of exposure to chemicals.

“It is the policy of Mary Washington Healthcare to provide reasonable accommodations to qualified individuals with a disability who are applicants for employment or Associates.”

Compensation Pay Range:

$37.56 - $56.34

Working at Mary Washington Healthcare

Whether you are a new grad, experienced clinical professional or wanting to begin a career in healthcare, there is no better place than Mary Washington Healthcare. As a Great Place to Work-Certified company we treat our Associates like family – with respect, understanding, and communication. Safety is our top priority As a healthcare system, patient and Associate safety is our priority which is why all Associates will be required to take the following vaccines*: Annual flu vaccine *MWHC reserves the right to amend this list at any time. Medical and Religious exemptions may apply,. Will be discussed at interview.