Accreditation Specialist

Job Description

We're looking for an Accreditation Specialist to work as part of the Quality & Outcomes Management Team to achieve cost effective health care throughout Texas Children's IDS and maintain necessary accreditation status for the organization.

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Key Responsibilities

• Supports the Continuous Service Readiness program
• Participates in the internal mock survey program, which includes planning, development of tools, training, conducting mock surveys, reporting findings and follow-up as needed
• Works with leadership to plan, facilitate, participate, and follow-up on findings of consultative surveys.
• Participates in actual unannounced JC/CMS/TxHHS surveys. Role includes preplanning, education, active participation in survey, and required follow-up.
• Participates in conducting annual ICM. Report findings and develop action plans. Monitor metrics on a monthly basis as required.
• Coordinates regulatory educational offerings including internal and external presentations
• Oversee JC Accreditation website and communicate to appropriate audiences. Maintains documents necessary for the system.
• Oversees and coordinates with IS the installation of Accreditation Manager Plus (AMP) site licenses. Provides education and training to the AMP end users. Represents Accreditation in formal and informal settings at TCH and in the healthcare community.
• Represents Accreditation at TCH committee meetings and programs, as assigned.
• Prepares agendas, reports, and minutes as assigned, on time and error-free
• Provide regulatory consulting and analysis services to TCH IDS staff and physicians.
• Serves as TCH liaison to JCR for coordination, scheduling, contracting, and billing of mock survey visits.
• Serves as JCR Advisory Panel representative.
• Communicates with Joint Commission SIG group for questions regarding interpretation of accreditation issues. Inform appropriate parties of SIG ruling.
• Actively commits to the on-going development of self and maintain current knowledge of accreditation and regulatory standards.
• Develops regulatory articles and newsletters for the organization error free and on time
• Develops presentations with style, accuracy and professionalism as evidenced by error free presentation. Includes not only power point but written material as well.
• Maintains up to date knowledge of JC/CMS/TxHHS regulations for all applicable programs, as evidenced by direct observation by leadership.
• Conducts consultative mock surveys independently throughout the IDS. Evidenced by direct observation of leadership and customer feedback.
• Participation in other departmental operations.
• Provide input related to the development of the operating budget.
• Acts as a Facilitator or Team Leader on projects as assigned.
• Conducts special projects as assigned at the direction of leadership

Knowledge & Skills

• Strong knowledge of JC standards, CMS requirements, TxHHS regulations, medical staff rules, utilization and case management principles, and organizational practices.
• Excellent verbal and written communication skills, with the ability to convey complex regulatory and quality concepts.
• Ability to identify and solve problems independently, collaborate effectively across departments, and thrive in a team environment.
• Strong analytical, organizational, and project management skills.

Qualifications

• Required Education: Bachelor's Degree
• Licenses/Certifications: CPHQ; RN or other clinical discipline.
• Experience: Minimum 2 years of clinical, quality, and/or accreditation experience.

Skills: Strong communication, analytical skills, regulatory knowledge, and ability to collaborate across departments.

About Us

Since 1954, Texas Children's has been leading the charge in patient care, education and research to accelerate health care for children and women around the world. When you love what you do, it truly shows in the smiles of our patient families, employees and our numerous accolades such as being consistently ranked as the best children's hospital in Texas, and among the top in the nation by U.S. News & World Report as well as recognition from Houston Business Journal as one of this city's Best Places to Work for ten consecutive years.


Texas Children's comprehensive health care network includes our primary hospital in the Texas Medical Center with expertise in over 40 pediatric subspecialties; the Jan and Dan Duncan Neurological Research Institute (NRI); the Feigin Tower for pediatric research; Texas Children's Pavilion for Women, a comprehensive obstetrics/gynecology facility focusing on high-risk births; Texas Children's Hospital West Campus, a community hospital in suburban West Houston; Texas Children's Hospital The Woodlands, the first hospital devoted to children's care for communities north of Houston; and Texas Children's Hospital North Austin, the new state-of-the-art facility providing world-class pediatric and maternal care to Austin and Central Texas families. We have also created Texas Children's Health Plan, the nation's first HMO focused on children; Texas Children's Pediatrics, the largest pediatric primary care network in the country; Texas Children's Urgent Care clinics that specialize in after-hours care tailored specifically for children; and a global health program that is channeling care to children and women all over the world. Texas Children's Hospital is affiliated with Baylor College of Medicine, one of the largest, most diverse and successful pediatric programs in the nation.

To join our community of 15,000+ dedicated team members, visit texaschildrenspeople.org for career opportunities.

Texas Children's is proud to be an equal opportunity employer. All applicants and employees are considered and evaluated for positions at Texas Children's without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, gender identity, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.