Summary:
This position is responsible for accreditation and regulatory compliance preparation activities for UNC Health. This position is part of UNC Health Unified Quality serving all UNC Health. The Accreditation Manager coordinates multi-disciplinary team participation in Joint Commission, state and federal surveys. The position also provides technical assistance to stakeholders on matters pertaining to the application of Joint Commission standards, CMS regulations and North Carolina Division of Health Service Regulation requirements.
Responsibilities:
Leading People – Leads Team toward meeting the organization's vision, mission, and goals. Provides an inclusive workplace that fosters the development of others, facilitates cooperation and teamwork, and supports constructive resolution of conflicts. Treats sensitive or confidential information appropriately. Works to improve and reinforce performance of others. Delegates assignments, clarifies expectations and holds others accountable for achieving results related to their area of responsibility. Encourages workforce engagement by building a commitment to excellence. Works collaboratively toward solutions that accomplish organizational objectives.
Accreditation and Survey Management- Maintains extensive knowledge of the most current accreditation standards and related state and federal regulations. Effectively manages Joint commission, CMS and Division of Health Services Regulation (DHSR) surveys. Prepares and coordinates written responses and follow-up. Ensures organizational readiness and ongoing compliance with standards and regulations across UNC Health. Leads activities designed to monitor and improve compliance with standards, including focused tracers, mock surveys and educational sessions.
Investigations and Regulatory Standard Management- Coordinates investigations and responses to complaints received from The Joint Commission. Participates in root cause analysis review of sentinel events. Assists with development and monitoring of corrective action plans. Provides guidance on the interpretation and application of Joint Commission standards, state and federal regulations for the organization's stakeholders. Prepares policies and educational materials required for accreditation and regulatory compliance.
Leading Change - Initiates and manages change, removes barriers or accelerate its pace. Communicates a compelling vision and need for change that generates excitement, enthusiasm, and commitment to the process. Clearly communicates the direction, required performance, and challenges of change to all involved parties. Identifies and enlists the support of key individuals and groups to move the change forward. Serves as a role model by demonstrating commitment to innovation and continuous improvement in organizational performance.
Results Driven - Exceeds departmental and organizational goals and customer expectations. Participates in decision making that produce high-quality results by applying knowledge, analyzing problems, and calculating risks. Consistently conveys that customers are the highest priority. Communicates in a manner that promotes and sustains customer satisfaction and encourages others to do the same. Understands the overall financial performance of the organization and applies financial concepts and practices to establish and maintain realistic budgets. Uses financial information to monitor budgetary responsibilities.
WAYNE
Other information:
Education
Bachelor's Degree in Nursing (BSN) or related field.
Licensure/Certification
No licensure or certification required.
Experience
Seven (7) years of experience in administration or patient care in a hospital setting. One (1) year of managerial experience required.
01.8760.NUR-860
Job Details
Legal Employer: Wayne Health
Entity: Wayne UNC Health Care
Organization Unit: Perf.Improvemnt
Work Type: Full Time
Standard Hours Per Week: 40.00
Work Assignment Type: Onsite
Work Schedule: Day Job
Location of Job: WAYNE MED
Exempt From Overtime: Exempt: Yes
