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Accreditation Compliance Officer

University of Toledo
Ohio, United States
Salary Not Specified
Date posted
Oct 26, 2023

Title: Accreditation Compliance Officer

Department Org: Quality Management - 110050

Employee Classification: J1 - Salaried Full Time HSC

Bargaining Unit: Professional Staff Association

Primary Location: Health Science Campus Hospital

Shift: 1

Start Time: 0800 End Time: 0500

Posted Salary: Salary to commensurate with education and experience

Float: False

Rotate: False

On Call: False

Travel: False

Weekend/Holiday: False

Job Description:

Responsible for coordination and monitoring of the hospital medical accreditations, certifications, and regulatory compliance survey processes to include Center for Medicare and Medicaid Services, Joint Commission, Ohio Department of Health, and other disease specific programs. Stays abreast of program manuals/standards, laws, and regulations that affect organizational compliance. Acts as a liaison to government agencies and coordinates clinical site visits for regulators.

Prepares all documents for Joint Commission applications and other certification programs. Prepares and presents vulnerabilities and compliance reports to Senior Leadership Team. Completes ODH hospital registration documents and responds to all requests from regulatory bodies related to complaint surveys, onsite surveys, and related action plans. Investigates potential compliance violations and prepares corrective action plans as necessary. Performs ongoing education and conducts audits and mock surveys to track compliance with standards to maintain a continuous state of readiness. Reports directly to Senior Leadership and Chief Medical Officer.

Minimum Qualifications:

• Bachelor’s Degree required.
• Five (5) year’s previous experience in a hospital environment required.
• Five - Seven (5-7) year’s previous experience involving medical regulatory, hospital accreditation and/or certification programs required.
• Understanding of the hospital performance improvement and use of performance improvement statistical tools.
• Project management and audit experience.
• Experience in formal/informal training and educational program development.

Communication and other skills:
• Establishes relationships and networks across a broad range of people and groups, including physicians.
• Protects privacy and confidentiality, handles highly sensitive material.
• Shares information, observations, and conclusions clearly and promptly.
• Demonstrates effective and culturally appropriate communications.
• Utilizes effective communication to provide excellent communication services.
• Able to graph and analyze data
• Adheres to principles of infection control.
• Serves as an Ambassador of the University of Toledo in the community, demonstrating the institution’s values, service, and mission.

Preferred Qualifications:

• Certified Compliance Professional Preferred

Conditions of Employment:

To promote the highest levels of health and well-being, the University of Toledo campuses are tobacco-free. To further this effort, the University of Toledo Health Science Campus Medical Center is requiring candidates for employment to be nicotine-free. Pre-employment health screening requirements will include cotinine (nicotine) testing, as well as drug and other required health screenings for the position. With the exception of positions within University of Toledo Main Campus and the University of Toledo College of Medicine and Life Sciences, the employment offer is conditional upon successful completion of a cotinine test and Occupational Health clearance.

Equal Employment Opportunity Statement:

The University of Toledo is an equal opportunity, affirmative action employer. The University of Toledo does not discriminate in employment, educational programs, or activities on the basis of race, color, religion, sex, age, ancestry, national origin, sexual orientation, gender identity and expression, military or veteran status, disability, familial status, or political affiliation.

The University is dedicated to the goal of building a culturally diverse and pluralistic faculty and staff committed to teaching and working in a multicultural environment and strongly encourages applications from women, minorities, individuals with disabilities, dual-career professionals and covered veterans.

The University of Toledo provides reasonable accommodation to individuals with disabilities. If you require accommodation to complete this application, or for testing or interviewing, please contact the Human Resources Department at 419-530-4747 between the hours of 8:30AM and 5:00PM or apply online for an accommodation request.

Computer access is available at most public libraries and at the Office of Human Resources located in the Center for Administrative Support on the Main Campus of the University of Toledo.

Advertised: 25 Oct 2023 Eastern Daylight Time
Applications close:

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