"Accreditation Senior Officer - Accreditation & Compliance"

Scope of Position

The Accreditation Senior Officer is responsible for implementing the administrative aspects of the accreditation strategies developed by the Director of Accreditation and Licensure. This will include the monitoring of operationalizing policies and procedures, conducting regulatory audits and drills, monitoring compliance, and assisting with continual survey readiness. The Accreditation Senior Officer will work directly with members of the faculty and staff to assure provision of high quality patient care while ensuring regulatory compliance of all current and planned inpatient hospital beds (~500+ future), and all ambulatory sites including The James outpatient care, Stephanie Spielman Comprehensive Breast Center, Martha Morehouse Tower, New Albany, Dublin, Powell, all mammography regional sites, and all future provider-based locations.

This position directs the hospital's operations & activities to comply with all accreditations, regulation, & licensing requirements for all health care sites & services across the continuum. Translates various accrediting, regulatory & licensing agency requirements into action plans to achieve positive survey/audit reviews and implements systems to effectively monitor compliance to standards & to implement new processes to meet new requirements. This position serves as a professional resource throughout the health system to interpret Joint Commission standards, Ohio Department of Health, Center for Medicare regulations and other accrediting agencies applicable to the hospital and ambulatory environment.

Position Summary

The Accreditation Senior Officer will review and analyze laws, regulations, and accreditation standards to determine operational impact. Prepare documents and reports related to policies and procedures, accreditation, and regulatory functions. Monitor hospital compliance for accreditation to include The Joint Commission, ODH, CMS, and others as determined appropriate. In addition to these regulatory bodies, the leader will assist with the Commission on Cancer, and the accrediting bodies such as the National Accreditation Program for Breast Centers (NAPBC) and other voluntary disease accreditation programs supported by The James.

Minimum Qualifications

Master's Degree in Nursing or a Healthcare related field or equivalent combination of education and experience. Current Ohio RN License. 4 years of relevant experience required. 4-8 years of relevant experience preferred.

Function: Health Care Administration

Subfunction: Accreditation

Band: Specialized

Level: S3