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Posted: 12-Feb-25
Location: Chapel Hill, North Carolina
Categories:
Internal Number: 9999-INFOR-158194
Description
Become part of an inclusive organization with over 40,000 teammates, whose mission is to improve the health and well-being of the unique communities we serve.
Summary:
Prepare hospital leaders/teammates for surveys and the accreditation process through mock surveys, focused tracers, articles, computerized learning modules, newsletters, presentations, accreditation websites, and consults with various departments.
Responsibilities:
1. Facilitate the interpretation of the Joint Commission Standards, Center for Medicare and Medicaid regulations, DNV standards, and any other required regulatory agency standards (hereto referred to as standards and regulations) with/for organization's leadership team.
2. Ensure organizational readiness and ongoing compliance with the standards and regulations across the organization.
3. Report the status of hospital-wide standards compliance to organizational leaders.
4. Develop and provide educational training/support to organization teammates.
5. Coordinate investigations and reply to patient/family complaints sent to the organization by the Joint Commission or other regulatory agency.
6. Manage TJC/CMS/Division of Health Services Regulation (DHSR) and/or DNV surveys effectively. Prepare and coordinate written responses to surveys, as needed.
7. Participate in the Patient Safety Team and root cause analysis of patient safety/sentinel events. Create/assist with action planning to prevent these events in the future.
8. Maintain extensive knowledge of the most current accreditation, certification, and licensure requirements and standards, independent judgment, decision-making, data collection, validation and analysis techniques, Quality Improvement concepts and tools, risk management, operational policies, and patient safety and care standards.
Other Information
Other information:
Education Requirements:
? Bachelor's degree in an appropriate discipline or equivalent.
Licensure/Certification Requirements:
? None required
Professional Experience Requirements:
? With a Bachelor's degree, requires two (2) years of experience in administration, project coordination, or patient care in a hospital setting.
? With an Associate's degree, requires four (4) years of experience in administration, project coordination, or patient care in a hospital setting.
Knowledge/Skills/and Abilities Requirements:
? Ability to read, analyze, and interpret common scientific and technical journals, financial reports, and legal documents. Ability to respond to common inquiries or complaints from customers, regulatory agencies, or members of the business community. Ability to write speeches and articles for publication that conform to prescribed style and format. Ability to effectively present information to top management, public groups, and/or boards of directors. Ability to apply advanced mathematical concepts such as exponents, logarithms, quadratic equations, and permutations. Ability to apply mathematical operations to such tasks as frequency distribution, determination of test reliability and validity, analysis of variance, correlation techniques, sampling theory, and factor analysis. Ability to define problems, collect data, establish facts, and draw valid conclusions. Ability to interpret an extensive variety of technical instructions.
Job Details
Legal Employer: STATE
Entity: UNC Medical Center
Organization Unit: Accreditation Regulatory
Work Type: Full Time
Standard Hours Per Week: 40.00
Salary Range: $30.73 - $44.18 per hour (Hiring Range)
Pay offers are determined by experience and internal equity
Work Assignment Type: Onsite
Work Schedule: Day Job
Location of Job: US:NC:Chapel Hill
Exempt From Overtime: Exempt: Yes
This is a State position employed by UNC Health Care System with UNC Health benefits. If, however, you are presently an employee of another North Carolina agency and currently participate in TSERS or the ORP, you will be eligible to continue participating in those plans at UNC Health.
Qualified applicants will be considered without regard to their race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.
UNC Health makes reasonable accommodations for applicants' and employees' religious practices and beliefs, as well as applicants and employees with disabilities. All interested applicants are invited to apply for career opportunities. Please email applicant.accommodations@unchealth.unc.edu if you need a reasonable accommodation to search and/or to apply for a career opportunity.