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Accreditation Analyst

Rush University Medical Center

This is a Contract position in Chicago, IL posted May 14, 2019.

Job Title: Accreditation Analyst Department: Accreditation & Regulation Shift: 1st Specialty: Job Number: 2019-0754 Date Posted: 03/22/2019 Position Type: Professional Job Qualifications: Accreditation Analyst Supports Accreditation Manager for Continual Survey Readiness (CSR) efforts at RUMC, with a focus on ambulatory locations, promoting a standard and effective approach to ensure that the organization is continually ready for an accreditation survey.

Through these activities, this individual promotes a culture of CSR at every level of RUMC.

Exemplifies the Rush mission, vision and values and acts in accordance with Rush policies and procedures.

Position Responsibilities: Coordination and support of CSR activities across RUMC, with a focus on ambulatory locations Support Accreditation Manager in all CSR activities Assist with coordination and submission of the annual Focused Standards Assessment (FSA) and conducts follow-up on issues Support the organizations survey readiness team activities Organize mock, individual, patient, department, and system tracers Schedule, collect, and analyze data from leadership rounds and other regulatory rounds at RUMC Develop, display, and distribute accreditation and regulatory-focused aids and materials Develop and distribute periodic communications to leadership/staff Responsible for coordinating and scheduling environment of care rounds Train leaders throughout the organization in processes of conducting system and program-specific tracers, utilizing data collection tools, and how to drill-down when needed Maintain all required documentation that will be requested by announced TJC surveyors Support development of communication tools for regulatory updates Support policy management functions across RUMC Analysis
– submit, extract and analyze data and information collected in the organization related to current accreditation readiness.

Submit and analyzes compliance gaps identified through the FSA process Ensure that documents required by accreditors/regulators are updated and implemented in the organization Maintain key organizational databases e.g.

environment of care rounds data entry and coordination, etc.

Monitor results of Accreditation survey(s) conducted in past (e.g.

findings in which plans of correction have been implemented and in process); Analyze and aggregate data from various information sources not limited to above and create presentations for sharing this data on a regular basis Create and share databases to track regulatory trends and compliance Survey support during an accreditation, licensure, department of health or any type of regulatory survey.

This could include facilitating or coordinating the following activities: Notifying leadership and staff via various communication methods of ongoing survey; Notifying the team responsible for proving leadership during the survey including survey escorts, scribes, etc Finalizing with surveyors a schedule and distributing to all hospital leaders and staff; Accompanying surveyor as scribe or escort through the visit and coordinates feedback from other survey escorts and scribes Following up with survey findings with maintaining accurate and timely measures of success Research TJC standards, CMS Conditions of participation and other relevant regulatory standards and survey processes Other duties as assigned by Accreditation Manager Position Qualifications Include: B.S.

in a health related field.

Working knowledge of CMS Conditions of Participation, State Licensing Code and The Joint Commission standards.

Excellent written communication skills, organizing, data management, and analytical skills, including excel database and powerpoint presentations, to design and implement monitoring and evaluation tools.

This role requires commuting and/or carpooling via Rush transportation to various RUMC locations in the Chicago-land area.

Company Highlights: Ranked among the top academic medical centers in the country, Rush University Medical Center is an outstanding place to enhance your career.

Everything we do centers on one goal: improving patient care.

Ranked among the top 20 best places to work in healthcare by Indeed.

Rush has been named one of the 100 Top Hospitals in the country by Truven Health Analytics three times.

The Association for the Accreditation of Human Research Protection Programs (AAHRPP) has awarded Rush full accreditation for three years.

Rush is one of the first academic medical centers in Illinois to receive this accreditation.

For the fourth consecutive time, Rush received Magnet status, the highest recognition given for nursing excellence.

Rush was the first hospital in Illinois serving both adults and children to receive the designation.

For the 12th consecutive time, Rush University Medical Center and Rush-Copley Medical Center received an A grade in a nationwide safety evaluation of hospitals, putting them among the top 2.2 percent of hospitals.

Rush is an equal opportunity employer.

We evaluate qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, and other legally protected characteristics.

Accreditation Analyst Supports Accreditation Manager for Continual Survey Readiness (CSR) efforts at RUMC, with a focus on ambulatory locations, promoting a standard and effective approach to ensure that the organization is continually ready for an accreditation survey.

Through these activities, this individual promotes a culture of CSR at every level of RUMC.

Exemplifies the Rush mission, vision and values and acts in accordance with Rush policies and procedures.

Position Responsibilities: Coordination and support of CSR activities across RUMC, with a focus on ambulatory locations Support Accreditation Manager in all CSR activities Assist with coordination and submission of the annual Focused Standards Assessment (FSA) and conducts follow-up on issues Support the organizations survey readiness team activities Organize mock, individual, patient, department, and system tracers Schedule, collect, and analyze data from leadership rounds and other regulatory rounds at RUMC Develop, display, and distribute accreditation and regulatory-focused aids and materials Develop and distribute periodic communications to leadership/staff Responsible for coordinating and scheduling environment of care rounds Train leaders throughout the organization in processes of conducting system and program-specific tracers, utilizing data collection tools, and how to drill-down when needed Maintain all required documentation that will be requested by announced TJC surveyors Support development of communication tools for regulatory updates Support policy management functions across RUMC Analysis
– submit, extract and analyze data and information collected in the organization related to current accreditation readiness.

Submit and analyzes compliance gaps identified through the FSA process Ensure that documents required by accreditors/regulators are updated and implemented in the organization Maintain key organizational databases e.g.

environment of care rounds data entry and coordination, etc.

Monitor results of Accreditation survey(s) conducted in past (e.g.

findings in which plans of correction have been implemented and in process); Analyze and aggregate data from various information sources not limited to above and create presentations for sharing this data on a regular basis Create and share databases to track regulatory trends and compliance Survey support during an accreditation, licensure, department of health or any type of regulatory survey.

This could include facilitating or coordinating the following activities: Notifying leadership and staff via various communication methods of ongoing survey; Notifying the team responsible for proving leadership during the survey including survey escorts, scribes, etc Finalizing with surveyors a schedule and distributing to all hospital leaders and staff; Accompanying surveyor as scribe or escort through the visit and coordinates feedback from other survey escorts and scribes Following up with survey findings with maintaining accurate and timely measures of success Research TJC standards, CMS Conditions of participation and other relevant regulatory standards and survey processes Other duties as assigned by Accreditation Manager Position Qualifications Include: B.S.

in a health related field.

Working knowledge of CMS Conditions of Participation, State Licensing Code and The Joint Commission standards.

Excellent written communication skills, organizing, data management, and analytical skills, including excel database and powerpoint presentations, to design and implement monitoring and evaluation tools.

This role requires commuting and/or carpooling via Rush transportation to various RUMC locations in the Chicago-land area.

Company Highlights: Ranked among the top academic medical centers in the country, Rush University Medical Center is an outstanding place to enhance your career.

Everything we do centers on one goal: improving patient care.

Ranked among the top 20 best places to work in healthcare by Indeed.

Rush has been named one of the 100 Top Hospitals in the country by Truven Health Analytics three times.

The Association for the Accreditation of Human Research Protection Programs (AAHRPP) has awarded Rush full accreditation for three years.

Rush is one of the first academic medical centers in Illinois to receive this accreditation.

For the fourth consecutive time, Rush received Magnet status, the highest recognition given for nursing excellence.

Rush was the first hospital in Illinois serving both adults and children to receive the designation.

For the 12th consecutive time, Rush University Medical Center and Rush-Copley Medical Center received an A grade in a nationwide safety evaluation of hospitals, putting them among the top 2.2 percent of hospitals.

Rush is an equal opportunity employer.

We evaluate qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, and other legally protected characteristics.