Accreditation & Regulatory Specialist - Accreditation & Clinical Compliance UI Health

Job Description

The University of Illinois at Chicago, UI Health & Hospital Systems is looking to hire the ideal candidate to fill the position of Accreditation and Regulatory Specialist within the Department of Accreditation & Clinical Compliance. The Accreditation and Regulatory Specialist leads and/or assists the Director in system wide activities to evaluate and improve adherence to Joint Commission accreditation standards and CMS Conditions of Participation, including ongoing readiness for accreditation surveys as well as regulatory complaint investigations. The mitigation of regulatory compliance risk will at all times focus on assuring the delivery of high quality, safe patient care.

Key Job Duties/Responsiblities

• Serves as resource for Joint Commission, CMS, and State licensing law interpretation.
• Regular review of websites and publications for changes in standards/requirements, with communication to relevant hospital personnel.
• Participation in webinars/teleconferences/seminars to stay current on regulatory updates and compliance strategies.
• Interpretation of relevance of standards in relation to hospital policies and practices.
• As necessary, contact with organizations or consultants for direction/advice on complex compliance issues
• Leads/assists in annual gap analysis ”Focused Standards Assessment” of compliance with Joint Commission/CMS standards, and tracks status via TJC tools as well as other internal methods.
• Utilizing quality improvement techniques and tools, leads/assists in the development and implementation of detailed action plans to achieve compliance, on a system-wide basis.
• Advises managers on how to develop and implement interventions to achieve and sustain compliance, as well as audits to measure effectiveness of new processes or action plans, including design of audit tools, sampling methods, and collation and display of data for analysis.
• Manages/assists with any compliance database system, including training, updates, security management, report generation, etc.
• Manages/assists with the hospital process for policy and clinical care guideline development, approval, dissemination, intranet posting, and archiving as legal records. This includes facilitation and support to the Hospital Management Policy and Procedure Committee.

• Develops/assists in time-line for Joint Commission survey preparation, identifying activities and personnel accountable for preparation activities. Leads/assists in these efforts, including advance preparation of scheduling, preparation sessions, escort coordination, documentation confirmation, etc. Provides progress reports to the department director, the TJC Compliance Committee, and others as needed.
• Responds to/assists with all unannounced surveys by TJC, CMS, and IDPH, or other regulatory groups as determined by medical center leadership.
• Responds to/assists with all “for cause” complaint investigations of Joint Commission or CMS/IDPH, including response to all surveyor information requests and assuring the appropriate administrative or clinical representatives attend and produce required policies, data, or medical record documentation.
• Coordinates all Tracer or rounds related to compliance activities, including scheduling, training, tool updates, and website updates.
• Tracks deadlines for all regulatory/accreditation activities, and assures all responses are on target to meet deadline, or escalated through necessary reporting structure to meet necessary compliance timeframes.
• Consults and advises responsible administrators regarding Joint Commission disease certification standards interpretation or preparation for site visits as necessary.
• Collaborates with the Safety and Risk Management department and Safety Goal teams, to provide strategies, tools, and approaches to achieve compliance with Joint Commission and evidence based practices.
• Develops or helps maintain an Accreditation/Regulatory website for the hospital as a resource to all employees.
• Research external sources for compliance strategies that will not only meet standards, but promote evidence based care. Sources should minimally include Joint Commission, Vizient, and Institute for Healthcare Improvement.
• Educate hospital leadership and personnel on the benefits and risks associated with regulatory compliance in terms of value to accreditation, patient care, public reputation, and financial viability.

Minimum Accepted Qualifications

CREDENTIALS TO BE VERIFIED BY PLACEMENT OFFICER

• Bachelor’s degree required in Nursing, Public Health, Business Administration, Business, Health, or Operations Management, Environmental or Natural Science, or other discipline related to the Healthcare field.

• Two (2) years (24 months) of work experience with the standards and survey process of an organization that includes accreditation required.

• Demonstrated previous experience with Joint Commission standards and survey readiness process required

• As required by the position to be filled, education, training and/or work experience in the area of specialization inherent in the position may be required in meeting credential requirements #1 and #2 above.

**Applicants possessing a Master's degree in Nursing, Public Health, Business Administration, Business, Health, or Operations Management, Environmental or Natural Science, or other discipline related to the Healthcare field meet the requirements of #1 above.

Preferred Qualifications

Advanced degree in healthcare or a healthcare related field preferred, such as nursing, laboratory, public health, healthcare administration, health information management, healthcare law, etc.

Healthcare accreditation certification (ie.CJCP/CSHA) or quality certification (CPHQ) preferred Five (5) years of experience in health care environment preferred

Previous quality improvement experience preferred

Working knowledge of CMS Conditions of Participation and State Laws preferred

To Apply: For fullest consideration, please complete an online application by clicking the Apply for Position button below.

Please upload all valid certifications and transcripts within the document section of your online application. Documentation of high school completion (official transcripts, copy of diploma or GED certificate) may be required in order to be eligible for this position within the University of Illinois Hospital and Health Sciences System. Please have documents on hand in the event they are requested.

All civil service positions require an exam. The exam for this position is a Credentials Assessment.

Credential Assessment Exam Scoring Information:

You will not be required to report in person for this exam. The updated online application and all uploaded, relevant documents, such as a resume and/or college transcript will be used in the calculation of the exam score. These documents should be uploaded prior to the position close date.

When completing your online application, please be sure to provide detailed information about your job knowledge and specific duties and responsibilities, as your qualifications for any Civil Service position will be primarily determined based on what is contained in the application. Dates of employment and if employed on a full or part time basis (including number of hours per week) must be indicated for each position held. Additional consideration will be given to supporting documentation i.e. resume, transcripts, licenses, and certifications so please be sure to attach all applicable documents.

A degree or college coursework is required for this position. You MUST provide official transcripts.

Transcripts/Licenses/Certifications MUST be uploaded electronically to your online application through the "Documents" page on the Civil Service Employment Application (page 4). Be sure to select the appropriate document type before uploading the document.

If your educational institution provides electronic transcripts, please have them sent to kbridgey@uic.edu

If your educational institution doesn’t provide electronic transcripts, they must mail the transcripts to:

University of Illinois at Chicago
Recruitment and Staffing
Human Resources Building Room 109
715 S. Wood Street M/C 862
Chicago IL 60612
Attn: HB1389 - Accreditation and Regulatory Specialist - KB

If an application and all applicable forms, transcripts, and supporting documents are not submitted by the close date, the applicant/employee will not be considered for this position and will be denied.

For fullest consideration, the above mentioned requirements must be submitted no later than Friday, June 18, 2021.

We appreciate your interest in employment at the University of Illinois at Chicago.

The University of Illinois is an Affirmative Action/Equal Opportunity Employer.

This position requires Illinois residency within 180 days of the hire date.