Accreditation and Regulatory Specialist

Function of Job

Under direct supervision from a designated supervisor, and in conjunction with administrative staff, Accreditation and Regulatory Specialists evaluate and improve adherence to relevant regulatory and accreditation standards including assisting with ongoing readiness for regulatory and accreditation surveys and regulatory complaint investigations. The focus on regulatory compliance is meant to ensure a high quality response to regulatory actions.


A(n) Accreditation and Regulatory Specialist typically -

1. keeps informed of pending industry changes, trends, and best practices and assesses the potential impact of these changes on organizational processes.
2. interprets regulatory rules or rule changes and ensures that they are communicated through multiple mechanisms, including policies and procedures.
3. manages/assists in ongoing and comprehensive risk assessment to identify compliance gaps that need to be resolved or mitigated.
4. utilizes quality improvement techniques and tools to assist with the development and implementation of detailed action plans to achieve compliance on a system-wide basis.
5. advises managers on how to develop and implement audits to measure the effectiveness of new processes or action plans, including the design of audit tools, sampling methods, and the collation and display of data for analysis.
6. manages/assists with the compliance database system including training, updates, security management, report generation, etc.
7. manages/assists with policy and guideline development, approval, dissemination, intranet posting, archiving, and committee support.
8. develops/assists in meeting deadlines that are relevant to survey preparation by identifying necessary preparation activities and personnel accountable for survey completion, as well as organizing schedules, documents, reports, and mock tracer simulations.
9. responds to/assists with all “for cause” complaint investigations including responding to all surveyor information requests, assuring that the appropriate representatives produce required policies, data, or medical record documentation.
10. tracks deadlines for all regulatory/accreditation activities, assuring that all responses are on target to meet deadlines, and if they are not, that activities are escalated to meet necessary compliance timeframes.
11. communicates regulatory information to multiple departments and ensures that information is interpreted correctly, educating leadership and employees on the benefits and risks associated with regulatory compliance in terms of value to accreditation, patient care, public reputation, and financial viability.
12. develops or helps to maintain a regulatory/accreditation website as a resource for all employees.
13. maintains an inventory or registry of other related accreditations.
14. researches external sources for compliance strategies that will not only meet standards, but promote evidence-based care.
15. collaborates with relevant departments, teams, and/or personnel to provide strategies, tools, and approaches to achieve compliance through evidence-based practices.

CREDENTIALS TO BE VERIFIED BY PLACEMENT OFFICER

1. Bachelor's degree required in Nursing, Public Health, Business Administration, Business, Health, or Operations Information Management, Environmental or Natural Science, or other discipline related to the Healthcare field.
2. Two (2) years (24 months) of work experience with the standards and survey process of an organization that includes accreditation.

* 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 Information Management, Environmental or Natural Science or other discipline related to the Healthcare field meet the requirements of #1 above.

1. Knowledge of business and management principles involved in strategic planning, resource allocation, human resources modeling, leadership technique, production methods, and coordination of people and resources
2. Knowledge of principles and processes for providing customer services. This includes customer needs assessment, meeting quality standards for services, and evaluation of customer satisfaction in determination of compliance decisions.
3. Knowledge of data collection, sampling, and analysis techniques.
4. Strong organizational skills, including accuracy and attention to detail.
5. Skill in managing one’s own time and the time of others.
6. Skill in systems analysis - determining how a system should work and how changes in conditions, operations, and the environment will affect outcomes.
7. Computer skills, including use of Microsoft Office products as well as databases supporting the compliance program.
8. Ability to review, accurately interpret, and communicate complex standards and regulations.
9. Ability to adapt to and lead others in rapidly changing situations.
10. Ability to develop constructive and cooperative working relationships with others, and maintaining them over time.
11. Ability to communicate effectively both verbally and in writing, as appropriate for the needs of the audience.
12. Ability to use logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions or approaches to problems.