Job Category:

Nursing - Registered Nurse

Work Shift/Schedule:

8 Hr Morning - Afternoon

Northeast Georgia Health System is rooted in a foundation of improving the health of our communities.

About the Role:

Job Summary

The Accreditation Manager will provide leadership in coordinating accreditation activities for the Acute Care Services and Ambulatory Surgical Centers of Northeast Georgia Medical Center. A primary focus of the position will  be overseeing compliance with ISO requirements (including control of documented information and audits) and policy management for the system. He/She will support the Director of Quality and Accreditation in ensuring the requirements of the Quality Management System (QMS) for System Level Acute Care Services and Ambulatory Surgical Centers are determined, implemented, and maintained.  
 

Minimum Job Qualifications

• Licensure or other certifications: Current licensure as an RN in the State of Georgia.

• Educational Requirements: Bachelors Degree.

• Minimum Experience: Must be a registered nurse with at minimum of five (5) years of Accreditation experience (preferably DNV and/or ISO) or related experience in a healthcare environment.

• Other:

Preferred Job Qualifications

• Preferred Licensure or other certifications:

• Preferred Educational Requirements: Masters Degree.

• Preferred Experience: Experience with policy management. Two (2) years of progressive experience in management or supervisory/leadership roles

• Other:

Job Specific and Unique Knowledge, Skills and Abilities

• Strong written and verbal communication skills

• Strong organizational skills 

• Excellent interpersonal and facilitation skills 

• Knowledge of local, state and national accreditation requirements and survey activities

• Knowledge of ISO requirements, including control of documented information

• Ability to prioritize duties and projects; willing to work flexible hours to meet the needs of the department
   

Essential Tasks and Responsibilities

• Manages regulatory and/or accreditation processes for the System Acute Care Hospitals and Ambulatory Surgical Centers, specifically CMS, DNV, Georgia Rules and Regs, and ISO.  Reports and communicates findings, facilitating the completion of action plans, and monitoring.

• Manages ISO audit process, assuring loop closure. 

• Supports quality oversight structures to assure regulatory requirements are met.  

• Manages policy and document control processes for system, including Policy Steering Committee oversight. Collaborates with others in the organization to promote consistent and standardized operations related to document control.

• Maintains administrative/strategic oversight for the document control system and oversees current and standardized operations within the system.

• Contributes expertise to hospital/system and medical staff committees, including meeting coordination and facilitation, as requested.

• Communicates and/or escalates unresolved issues, following established policy.

• Reviews and manages contracts pertaining to role functions, as assigned.

• Recognizes and operationalizes work needed to support annual pillars/goals.

• Collaborates with the Director to determine fiscal requirements, preparing budgetary recommendations.

• Ensures that staff are current in competency, assessments, licensure, certifications, and other annual training.

• Completes special projects or assignments, as requested.

• Leads as a lean leader by upholding Quest for Excellence Principles. Oversees daily management system deployment for all areas of responsibility. Maintains high proficiency in Quest for Excellence behaviors and tools

• Interviews, hires, supervises, counsels, evaluates, and disciplines departmental personnel according to organizational guidelines and policies. Sets clear guidelines and expectations for employees. Holds employees accountable for doing their part to achieve results.

• Assesses, coaches, and evaluates staff’s level of performance.

• Provides daily and periodic guidance, support, and resources to departmental staff to facilitate high quality performance and achievement of organizational goals.
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Physical Demands