Director of Accreditation at Albany Medical Center

Department/Unit:Quality ManagementWork Shift:Day (United States of America)Salary Range:$119397.28 - $191035.65The Director of Accreditation and Certification implements directs and facilitates activities that support the institutions ability to achieve and remain a successfully accredited health care organization that is continuously ready for patients every day. For accreditation and certification survey related activities the director will serve as the on-site survey leader as a resource and consultant to the organization as a liaison between the hospital and the accrediting organization and as an expert in continuous improvement processes.This role reports to the Associate Vice President of Accreditation and Quality and supervises accreditation team members.Essential FunctionsDirects all organizational Continuous Survey Readiness Activities which include managing facilitating or coordinating the following activitiesDirecting the completion and submission of accreditation/certification administrative activities in collaboration with operational partnersCoordinating an ongoing readiness assessmentUpdates accreditation and certification portal to reflect hospitals services Prepares for all accreditation and certification on-site surveys (together with real-time coordination facilitation and follow-up)Preparing the organizational response to unannounced accreditation on-site surveysProvides staff education andtrainingConsults on and interprets standards (CMS New York State Department of Health and Accreditation)Communicates accreditation/certification/regulatory informationCollaborates with others in continuous improvement processes including data collection analysis and reportingCollaborates with others in policy and procedure development and reviewDevelopment of tools(checklists data collection forms) for conducting individual auditsa nd assessment surveysOversees the collection and distribution of audit dataCollaborate with the professional education department on the development and distribution of materials related to standards complianceDevelopment and distribution of periodic communications to update organizational leaders and staff on new quality/safety issues or initiatives on-site survey information and any changes to standards or the interpretation of accreditation/certification standardsParticipates in employee orientation activities as required by the organizationProvides education to staff as needed regarding new quality/safety initiativesConducts periodic meetings with managers to update their knowledge of accreditation standards and regulatory/organizational issues and trends uncovered during readiness activitiesFacilitates annual collection of information/data required to participate in Leapfrogs Hospital Grade. The Director will communicate as needed with relevant staff and leadership to assure successful participation.Facilitates ad hoc performance improvement groups focused on clinical and accreditation standard compliance.QUALIFICATIONSMasters Degree in Nursing or a healthcare-related degree required7 to 10 years of applicable healthcare experience5 years in direct patient care nursingRelated experience with quality measures accreditation standards and related compliance processesThank you for your interest in Albany Medical Center!Albany Medical is an equal opportunity employer.This role may require access to information considered sensitive to Albany Medical Center its patients affiliates and partners including but not limited to HIPAA Protected Health Information and other information regulated by Federal and New York State statutes. Workforce members are expected to ensure that:Access to information is based on a need to know and is the minimum necessary to properly perform assigned duties. Use or disclosure shall not exceed the minimum amount of information needed to accomplish an intended purpose. Reasonable efforts consistent with Albany Med Center policies and standards shall be made to ensure that information is adequately protected from unauthorized access and modification.Required Experience:Director Key Skills Crisis Management,Marketing,Public Relations,Fundraising,Media Relations,Constant Contact,Strategic Planning,Social Media Management,Team Management,Public Speaking,Wordpress,Writing Skills Employment Type : Full-Time Experience: years Vacancy: 1 Monthly Salary Salary: 119397 - 191035