Accreditation Regulatory Specialist
Lake County IL
Waukegan, Illinois, United States
4d ago

Do you want a career where you can truly make a difference? The Lake County Health Department and Community Health Center is one of the largest human service providers in Lake County.

We live our mission each day, promoting the health and well-being of all who live, work, and play in Lake County. If you are passionate about giving back and ready to be a part of an innovative team, we are looking for you! About the Role : The Accreditation Regulatory Specialist is responsible for leading and coordinating activities required for successful accreditation, licensing and certification.

This includes responsibility for developing and implementing systems and processes to sustain readiness for Joint Commission (TJC),Substance Abuse and Mental Health Services Administration (SAMHSA)Health Resources and Services Administration (HRSA), Illinois Department of Human Services (DHS) Illinois, Department of Healthcare and Family Services (HFS), Illinois Department of Mental Health (DMH), Illinois Division of Substance Use Prevention and Recovery (DASA), Illinois Department of Public Health (IDPH) and the Centers for Medicare and Medicaid (CMS), and others.

Utilizes leadership, project coordination, and facilitation skills to set clear expectations, bring diverse team members to consensus and achieve desired results.

Establishes quantitative measurement systems and transfers change management and performance improvement skills and knowledge to ensure ongoing operational improvement.

Hours : Monday - Friday (8 : 30am - 5 : 30pm) Skills and Experience Provide leadership and coordination for the organization, to maintain compliance with TJC, SAMHSA, HRSA, DHS, HFS, DMH, DASA, IDPH, CMS.

and other quality of care accreditation and regulatory standards. Provide leadership to operational efforts related to accreditation, licensing or certification that have critical organization wide impact.

This may include assisting with the development / implementation of new or revised processes, information technology solutions, and policies and / or procedures.

Works collaboratively with leadership to plan, facilitate and evaluate multidisciplinary process improvements relating to accreditation or regulatory initiatives.

Serve as a contact and resource for accrediting and licensing organizations. Leads change process through committee leadership / membership as needed.

Utilizes standardized methods for improvement efforts, including Rapid Improvement methods and project coordination. Also utilizes common concepts for statistical analysis, outcomes measurement, quality improvement tools, systems thinking, and operations improvement practices.

Develops content and communicates accreditation / regulatory related activities and information to all staff via newsletters or other forms of publications and communication.

Develops and implements staff education materials and forums related to this information, activity and processes. Develops and implements methods for ongoing review to assess the level of site visit / survey readiness.

Conducts prospective, concurrent and retrospective studies using a sound clinical and / or healthcare knowledge base and statistical analysis skills to support policy, procedure and system change.

Facilitates groups to assist in root cause analysis, Failure Modes Effect Analysis (FMEA) or other process improvement activities as required.

Creates and maintains a calendar / schedule of required and recommended activities for accreditation and licensure activities and milestones, and monitors for compliance Education, Qualifications, and Certification : Bachelor's Degree required.

Master's level preparation strongly preferred. Associate's degree in clinical area plus two years related experience may be considered in lieu of Bachelor's degree.

Requires 3-5 years' experience and knowledge of regulatory and accrediting standards. Experience with behavioral health standards highly desirable.

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