University of Iowa Health Care is seeking an Senior Compliance Coordinator - Accreditation to support activities to assess, plan, monitor and evaluate compliance with accreditation standards and regulations, including but not limited to: Joint Commission, Centers for Medicare and Medicaid Services (CMS) Conditions of Participation for Hospitals, State of Iowa Department of Inspection and Appeals, and other accrediting agencies as appropriate. The role manages, promotes, and conducts educational, service and other programs pertaining to Joint Commission compliance assessment and staff education including University of Iowa Community Clinics (UICC).Position Responsibilities:
- Responsible for implementation, maintenance and oversight of programs to ensure hospital compliance with all state and national regulatory and accreditation standards, at University of Iowa Hospitals and Clinics (UIHC) and off-site UI Health Care Ambulatory Care Clinics.
- Maintain knowledge regarding accreditation standards, a database, and a reference library of current initiatives being taken by accrediting agencies through timely review of regulatory guidelines, journals, and newsletters, and attendance at agency educational programs. Obtain and disseminate standards, regulations, etc., to those in the health system as necessary.
- Coordinate implementation of training programs and other educational efforts for staff. Assist in developing, implementing, and providing oversight for a system to assure that all staff are knowledgeable about regulatory standards.
- Provide direction to department heads, managers, supervisors, healthcare providers and staff to ensure health care services are provided in accordance with quality and safety standards established by state and federal regulations, and national accrediting bodies.
- Assist with implementation of training programs and other educational efforts to ensure all UI Health Care staff are knowledgeable about Joint Commission and CMS standards.
- Oversee maintenance of knowledge base regarding accreditation standards, including Joint Commission database and reference library of current safety standards and CMS regulations. Track current initiatives being taken by accrediting agencies through timely review of regulatory guidelines, journals, and newsletters.
- Assist with the management of Accreditation Manager Plus (AMP) for improvement in ensuring compliance with the accrediting and regulatory standards of the Joint Commission. Develop custom tracer content for special projects. Aggregate survey information for analysis and report to senior leadership.
- Assist with the UIHC onsite and Ambulatory Care Clinics Mock Survey Program. Plan and coordinate mock surveys and other audits as needed to monitor and ensure continuous compliance with Joint Commission clinical care and safety standards. Aggregate survey information for analysis and report to senior leadership.
- Assist with and oversee internal procedures for monitoring and detecting noncompliance, recommending corrective actions on such matters, and following-up to ensure that recommendations have been implemented. Coordinate standards review and monitoring activities, including annual or periodic reviews.
- Assist with periodic reports to the UI Health Care Committee on Accreditation, the University Hospital Advisory Committee and other governance and management entities regarding:
- Announced or potential changes in regulations and/or standards
- Monitoring and evaluation of compliance with all current regulations and/or standards
- Progress on implementation of new policies, procedures, and activities needed to assure continuing compliance
- Planned visits and surveys by external agencies and results of visits.
Required
- Master's degree or an equivalent combination of education and experience required
- Three years' experience program management in healthcare environment required.
- Demonstrated people skills and excellent verbal and written communication skills required.
- Must be self-organized, work independently, and have demonstrated team-building skills.
- Proficiency in Microsoft Office applications, including data management, is required.
- The position will require frequent travel to regional ambulatory care clinics in the state. Applicant must have a valid Driver's License, plus the ability to meet the University of Iowa Fleet Safety Program driving standards (University of Iowa Operations Manual Part V, Chapter 19).
- Proficiency in technical problem-solving for medical and technical processes required.
Desired
- In-depth knowledge of Joint Commission Standards and CMS Conditions of Participation preferred.
- Prior experience participating in Joint Commission surveys and state regulatory surveys.
- Poise in teaching and consulting, flexibility, and creativity in problem-solving, and excellent interpersonal skills desired.
Application Process: To be considered, applicants must upload a cover letter and resume (under the submission of relevant materials) that clearly address how they meet the listed required and desired qualifications of this position. Job openings are posted for a minimum of 14 calendar days. Successful candidates will be required to self-disclose any conviction history and will be subject to a criminal background check and credential/education verification.Up to 5 professional references will be requested at a later step in the recruitment process. For questions, contact Sharon Walther at ...@uiowa.edu.This position is not eligible for University sponsorship for employment authorization.