Saint Anthony Hospital · 1 day ago
Accreditation Manager
Chicago, IL
Full-time
Onsite
Mid, Senior Level
$98K/yr - $156K/yr
5+ years expSaint Anthony Hospital is seeking an Accreditation Manager to assist the Director of Quality and Accreditation in maintaining preparedness for regulatory and accreditation activities. The role involves integrating Joint Commission and regulatory requirements into policies, providing education on these requirements, and overseeing data collection for accrediting bodies.
Health CareHospitalMedical
Responsibilities
Integrate Joint Commission (JC) and regulatory requirements into organizational policies, procedures, and protocols
Provide education, guidance, and interpretation on JC/regulatory requirements to teams and committees to support continuous readiness
Serve as a member of selected teams/committees to represent accreditation readiness
Prepare and deliver reports and presentations on key JC topics and activities to relevant forums
Coordinate and oversee data collection and submission to JC, CMS, and other accrediting bodies
Support Environmental Safety and Emergency Management through knowledge of the Environment of Care (EC) and Life Safety Code (LSC) requirements
Develop and maintain continuous patient readiness programs in collaboration with senior leadership to ensure compliance with accreditation standards
Organize and conduct patient tracers in inpatient and outpatient areas as part of TJC accreditation requirements
Lead and evaluate tracer processes, oversee improvements identified through tracers and surveys
The authority to hire, separate, promote, demote, write and administer performance evaluations
Other job functions as assigned
Perform both essential and marginal job functions in a safe manner as identified by Saint Anthony Hospital and the respective department while adhering to the Hospital’s confidentiality norms and standards
Assume responsibility for knowing and maintaining established hospital and departmental objectives, policies/procedures
Participate in performance activities including problem identification, data collection, solution selection, implementation and evaluation. Also assist in the care and maintenance of departmental equipment and supplies as appropriate
Participate in staff meetings and other in-services, meetings or committees as required
Represent the organization by participating in professional organizations, continuing education, outside workshops, seminars, and meetings that relate to Accreditation. Participate on selected Hospital and Medical Staff committees, work groups, and task forces as indicated and appropriate
Qualification
Required
Bachelor's degree in Nursing with current Illinois Nursing license
Achieves Certified Joint Commission Professional (CJCP) certification within three years and maintains credential as defined by JC
Recommended 5 years of nursing experience
Fluent in EHR documentation and functionality
Knowledge of and experience with JC, Medicare Conditions of Participation and other regulatory requirements. Including: IDPH, OSHA, etc
Knowledge of and experience with the development of policies, procedures and protocols
Company
Saint Anthony Hospital
Saint Anthony Hospital is a healthcare organization that provides rehabilitation, behavioral health, pediatrics and surgical services.
1001-5000 employees
Funding
Current Stage
Late StageLeadership Team
Guy A. Medaglia
President, CEO
Cheryl Russell
Vice President and Chief Development Officer
Recent News
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