Location: Fairbanks, Alaska
This position leads, plans, coordinates, implements and evaluates facility(ies)/entity(ies) for preparedness and accreditation requirements. This position acts as a subject matter expert to leadership, staff and system teams related to accreditation requirements to ensure standards are met. Work processed by the incumbent is confidential and protected from discovery by subpoena pursuant to state, department of health services, the Joint Commission and CMS regulations
*Relocation, Bonus and Housing Assistance Available!
**Wage starts at $44.09/hr and INCREASES Based on Experience
About Fairbanks Memorial HospitalFairbanks Memorial Hospital is a non-profit facility owned by the Greater Fairbanks Community Hospital Foundation. A Joint Commission-accredited facility with 152 licensed beds, Fairbanks Memorial Hospital is the primary referral center for residents of Alaska's interior with a strong patient-to-nurse ratio and Shared Leadership Infrastructure. In addition to our exceptional clinical environment, our location offers incomparable lifestyle rewards away from work.
In Fairbanks, small-town living, spectacular natural beauty and endless recreation combine to create a one-of-a-kind place to live, work and play.
Monday - Friday
8 hour day shifts
40 hours per week with occasional overtime
Responsibilities Manages and implements TJC and CMS CoP requirements using standardized processes. Reviews, evaluates and assists in the development and implementation of system policies, procedures and guidelines as they relate to standards compliance. Makes recommendations on all facility matters related to compliance with Joint Commission and CMS CoPs, and supports national/ state/local regulations and/or professional standards that intersect with TJC and CMS. Continuous survey readiness. Works with facility leadership and staff to prepare for survey readiness. Conducts observations, tracers, building tours, document reviews and interviews to ascertain facility compliance with TJC and CMS standards, rules and regulations. Identifies and coordinates compliance activities with content experts such as infection control and EOC/LS Specialists. Documents findings and provides the facility with reports and recommendations for change. Maintains the Joint Commission application and organizational accesses. Supports and ensures completion of the periodic performance review(FSA). Assists and supports action planning for resolution of identified non-compliance with regulations and standards. Provides tools for ongoing measurement and reporting of compliance with regulatory standards. Oversees and supports the development of plans of correction. Then assists functional teams and department managers in the completion of corrective actions. Facilitates onsite surveys by TJC and CMS. Responds to notices of surveyor arrival at facilities by directing survey management activities, clarifying standards, and supporting and assisting the senior leadership team. Initiates and directs post survey activities to ensure the facility meets regulatory process requirements. Schedules and participates in unannounced surveys system-wide. Provides support and guidance to responders to life safety, environment of care, emergency management and infection control events. Evaluates events to ensure standards and regulatory requirements are not compromised. Reports to senior leadership on trends and recommends improvement strategies. Presents data and reports deficiencies identified during internal observations/tracers, and the status of implementation of action plans to senior leadership and at facility regulatory meetings. Reports facility survey readiness status on an ongoing basis. Updates senior leadership on system accreditation compliance trends and certification/accreditation bodies most frequently scored standards. Serves as a subject matter expert on internal and external accreditation standards. Provides information and education to address changes and gaps in compliance. Provides guidance to leaders and staff to ensure they understand the requirements. Serves on assigned committees. Schedules and maintains accreditation meetings, updating on current and future plans and procedures, capabilities and actions. Chairs the facility function team and is actively involved in any regulatory workgroup. Maintains accreditation expertise through independent study as well as attending education workshops, tracking and reviewing standards changes, reviewing professional publications, establishing personal networks, and participating in professional societies.
Performs all functions according to established policies, procedures, and accreditation requirements, as well as applicable professional standards. Provides all customers of Foundation Health with an excellent service experience by consistently demonstrating our core and leader behaviors each and every day.
Requires knowledge as typically obtained through a Bachelor's degree in nursing or other healthcare related field.
Requires a strong knowledge of regulations and standards within area of focus as typically attained with 5 years relevant experience in a hospital setting, plus 3 years regulatory experience. Requires the ability to manage programs, projects and databases. Requires demonstrated excellence in interpersonal and written communication skills. Must possess demonstrated flexibility in responding to the needs of multiple constituencies with a service oriented philosophy. Demonstrated ability to lead and facilitate interdisciplinary teams. Requires ability to perform complex statistical analysis and highly developed problem solving skills.
Prior experience with in a surveyor role and experience in process improvement, regulatory/accreditation programs, data management and analysis, including graphic development and presentations is also preferred. For clinical assignments, current clinical license/certification preferred.
Certified Joint Commission Professional (CJCP) or similar certification preferred.
Additional related education and/or experience preferred.
Foundation Health Partners is an EEO/AAP employer; qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status.