Who We Are:

St. John’s Episcopal Hospital is the only hospital providing emergency and ambulatory care to the densely populated, culturally and economically diverse, and medically underserved populations of the Rockaways and Five Towns in southern Queens County and southwestern Nassau County, New York. Celebrating over 110 years of community care, the 257-bed facility provides people of all faiths with comprehensive preventive, diagnostic treatment and rehabilitative services, regardless of ability to pay.

Come Grow With Us!

Type: Full-Time

Shift: Days

Hours: 8:00AM - 4:30PM

Pay Rate: $115,000 - $120,000 per year

Job Summary:

A member of EHS Accreditation/Regulatory team, the Accreditation Specialist is a key leader and participant in the systems continuous accreditation and regulatory readiness program. Responsible for providing direction and oversight for regulatory and accreditation compliance including The Joint Commission (TJC), State and Federal agencies. Drives EHS in maintaining preparedness for accreditation and licensure surveys.

Responsibilities:

• Plays a lead role in regulatory and accreditation survey preparation, survey visits and post survey activities.
• Assists in developing plans of correction resulting from survey activity. Track and trend all regulatory corrective actions using various methods, Tracers with AMP program, and Microsoft Excel.
• Develops tracers with multiple stakeholders. Tracers follow all of the Joint Commission standards and CMS regulations. Collects data on the readiness of the hospital.
• Communicates with team members on regulatory deficiencies when identified.
• Assists with the coordination of policies so that they remain current, in approved format, and are uploaded timely in accordance with regulatory requirements.
• Maintains all files and data entry for compliance with the accreditation requirements.
• Provides comprehensive reports to stakeholders, as appropriate, on accreditation and regulatory compliance

Requirements:

• Associate’s degree required
• Bachelor’s or Master’s degree preferred
• Valid New York State RN licensure with no enforcement actions preferred
• Knowledge of Quality Improvement methodology, group facilitation, project management, and healthcare regulatory event reporting requirements.
• Knowledge base includes TJC standards interpretation, CMS and NYSDOH regulations.
• Expertise with MS PowerPoint, Word, and Excel required.
• Previous accreditation/regulatory readiness experience preferred
• 3 years of experience in clinical operations and/or experience working in performance improvement, patient safety, risk management or quality management areas in the healthcare environment preferred.