Accreditation/ISO Compliance Officer - Part Time

If you are looking to make an impact on a meaningful scale, come join us as we embrace the Power of One!
 

We strive to be an employer of choice and establish a reputation for being a talent rich organization where Associates can grow their career caring for others. For over a century, we’ve served the health care needs of the people of Memphis and the Mid-South.
 

Leads and designs processes related to accreditation and ISO: 9001 compliance, including the Quality Management System and Internal Audit at both the System level and assigned facility. Serves as the subject matter expert in CMS Conditions of Participation, ISO: 9001, NIAHO, State agency, Internal Audits and other accreditation and certification requirements. Plans, directs, and implements risk-prioritized processes to support ongoing compliance and Quality Management System. Models appropriate behavior as exemplified in MLH Mission, Vision and Values.

 

Working at MLH means carrying the mission forward of caring for our community and impacting the lives of patients in every way through compassion, a deliberate focus on service expectations and a consistent thriving for excellence.

A Brief Overview
Leads and designs processes related to accreditation and ISO: 9001 compliance, including the Quality Management System and Internal Audit at both the System level and assigned facility. Serves as the subject matter expert in CMS Conditions of Participation, ISO: 9001, NIAHO, State agency, Internal Audits and other accreditation and certification requirements. Plans, directs, and implements risk-prioritized processes to support ongoing compliance and Quality Management System. Models appropriate behavior as exemplified in MLH Mission, Vision and Values.

What you will do

• Leads and directs the process for continuous accreditation and ISO: 9001 compliance at both the system level and for assigned facility(s).
• Develops and coordinates the measurement of internal compliance through data collection, tracking/trending, analysis, and monitoring. Presents findings and recommendations for improvement.
• Applies risk-based thinking to prioritize, design, and lead internal audits across the system; report results and facilitate corrective action plans.
• Upon identification of non-conformities, works with appropriate stakeholders to facilitate development of correction action plans and verifications of control.
• Educates all levels of Associates (leaders to frontline) on the principles and requirements of the Quality Management System, ISO: 9001, and accreditation standards and the processes required for compliance.
• Provides presentations and updates to facility/system leadership and management review committees regarding accreditation/ISO: 9001 results & compliance, internal audits/corrective action plans status, and any component of the Quality Management System.
• Leads the Hospital’s response to CMS investigations.
• Designs/develops processes and coordinates external audits (DNV, ISO: 9001).
• Provides expertise/advice during the development of clinical/operational/business policies and procedures to ensure CMS Conditions of Participation and accreditation, and ISO: 9001 standards are met or exceeded.

Education/Formal Training Requirements

• Required - Bachelor's Degree Allied Health
• Required - Bachelor's Degree Healthcare Administration
• Required - Bachelor's Degree Nursing
• Preferred - High School Diploma or Equivalent
• Preferred - Master's Degree Allied Health
• Preferred - Master's Degree Healthcare Administration
• Preferred - Master's Degree Nursing

Work Experience Requirements

• Required - organizing, directing and participation in process improvement and/or regulatory compliance program in a hospital setting 3-5 years
• Preferred - Substitutions allowed: In lieu of Bachelor's degree, the candidate must be a Registered Nurse or Allied Health Professional with five years of organizing, directing and participation in process improvement and/or regulatory compliance program in a hospital setting. 5-7 years
• Preferred - Substitutions allowed: In lieu of Bachelor's degree, the candidate must have a High school diploma or equivalent with seven years of organizing, directing and participation in process improvement and/or regulatory compliance program in a hospital setting. 7-9 years

Licenses and Certifications Requirements

• Preferred - Certified Professional in Healthcare Quality-CPHQ - National Association for Healthcare Quality

Knowledge, Skills and Abilities

• Demonstrated knowledge and expertise in CMS Conditions of Participation, ISO: 9001, NIAHO/State Agency/Internal Audit and other accreditation