Accreditation Coordinator

Job Description

Job Description

Accreditation Coordinator

Department/Care Stream: Accreditation/Compliance

LIA Reporting Structure:

Timecard Approver: Accreditation Manager

Primary: Accreditation Manager

Secondary: VP of Compliance and Risk Management

Status: Full-time

FLSA: Non-Exempt

Location: Admin Center

Pay Range: $27.40- $35.62/hr

EEO-1: Administrative Support Worker

Organization Information

WellSpace's mission is "achieving regional health through high quality comprehensive care." We believe that everyone deserves to be seen, no matter who you are, where you come from, where you work or what place you call home. At WellSpace, we see you!

We are driven to serve the whole person through comprehensive, integrated care, spanning medical, dental, behavioral health, and supportive services across the region. We do this by building a team of exceptional colleagues who are dedicated to our mission and becoming part of the communities we serve.

As the region's largest Community Health System, WellSpace utilizes a Confluence Model to integrate an internal network of healthcare modalities, including Federally Qualified Health Centers (FQHC), Certified Community Behavioral Health Center (CCBHC), Drug Medi-Cal and Specialty Mental Health programs, California's second largest 988 Suicide and Crisis Lifeline Center, an independent Risk Bearing Organization (WellSpace Nexus), and more into a seamless confluence of care.

To ensure the highest quality of care, WellSpace is accredited by the Joint Commission for Ambulatory Care, Behavioral Health and as a CCBHC. Further, it is certified by the Joint Commission as a Primary Care Medical Home and a Behavioral Health Home. WellSpace's crisis programs are accredited by the American Association of Suicidology and the International Council for Helplines.

Position Summary

The Accreditation Operations Coordinator supports organizational accreditation efforts through project coordination, documentation, interdepartmental collaboration, and support of WellSpace Health’s Confluence Model of care delivery across departments, programs, and Centers. This role coordinates accreditation and quality improvement projects related to organizational readiness and regulatory standards, including activities associated with The Joint Commission. Responsibilities include tracking performance improvement initiatives, compiling and interpreting data and reports, supporting accreditation software systems, and assisting with accreditation readiness training and education activities. The ideal candidate is detail oriented, analytical, resourceful, able to manage multiple priorities and deadlines, and thrives in a fast paced, collaborative environment.

Required Qualifications

• Associate’s degree preferred; OR appropriate work experience necessary to perform the essential functions of the job.
• Experience in project coordination, accreditation activities, program evaluation, performance improvement, and data analysis preferred.
• Strong analytical, organizational, problem solving, and multitasking skills with ability to manage competing priorities and deadlines.
• Ability to work independently, exercise sound judgment, and maintain accuracy in a fast paced environment.
• Excellent interpersonal, customer service, verbal, written, presentation, and documentation skills.
• Strong computer proficiency, including Microsoft Office, electronic medical records, spreadsheets, presentations, and other electronic systems.
• Ability to analyze, interpret, and contextualize findings into meaningful data, reports, and actionable information
• Ability to communicate effectively and collaborate with teams from a wide variety of cultural, ethnic, and socioeconomic backgrounds.
• Results and outcomes oriented with strong emphasis on teamwork, collaboration, and High Reliability standards.
• Adherence to infection control procedures, including hand hygiene, symptom self monitoring, masking, and social distancing protocols.

Essential Responsibilities

• Coordinate and support accreditation readiness, quality improvement, and compliance activities across departments, programs, Centers, care streams, and service locations.
• Support WellSpace Health’s Confluence Model through collaboration with Leadership, Innovation, and Accountability (LIA) leaders, operational teams, and cross functional departments.
• Conduct regular site visits, walkthroughs, tracers, readiness rounds, audits, and assessments to monitor compliance with accreditation and regulatory standards, including The Joint Commission.
• Identify areas for improvement, monitor trends and repeat findings, and support corrective actions and follow up activities.
• Track accreditation activities, readiness initiatives, performance metrics, corrective actions, timelines, and departmental deliverables to support ongoing survey readiness.
• Follow up with departments and leaders regarding overdue items, documentation gaps, corrective actions, and accreditation related requirements.
• Compile, analyze, validate, and interpret findings into meaningful reports, dashboards, and actionable information.
• Review accreditation documentation and evidence for completeness, consistency, organization, and survey readiness.
• Coordinate and maintain accreditation files, reports, trackers, meeting minutes, action items, and accreditation related software systems.
• Support accreditation surveys, mock surveys, regulatory reviews, readiness meetings, and related preparation activities.
• Assist with development of presentations, educational materials, tools, templates, and training resources related to accreditation and quality improvement.
• Support training and education activities related to accreditation standards, readiness expectations, and organizational practices.
• Promote reliable processes, aligned practices, and continuous improvement efforts that support patient safety, quality, experience, and operational excellence.
• Perform other job duties and responsibilities as assigned.

Benefits

Successful candidate will receive regionally competitive salary, above average health benefits at reduced costs, paid life insurance & long-term disability insurance, additional voluntary retirement plan with organizational match and no vesting schedule requirement.

• Paid bereavement and jury duty leave
• 11 paid holidays per year
• Paid time off
• Paid sick leave
• Flexible Spending Program
• Company paid malpractice insurance for all providers
• Professional development hours offered annually

Physical Demands and Work Environment

The work environment is characteristic of a typical healthcare clinic environment. The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. While performing the duties of this job, the employee is frequently required to sit; use hands and arms to reach. The employee is also required to stand; walk; and reach with hands and arms. The employee must occasionally lift and/or move up to 20 pounds. Specific vision abilities required by this job include close vision, distance vision, and the ability to adjust focus. The employee must also possess hearing and speech to communicate in person and over the phone. The noise level in the work environment is usually quiet.

The employee may be in contact with individuals and families in crisis who may be ill, using substances and/or not attentive to personal health and safety for themselves or their homes. The employee may experience a number of unpleasant sensory demands associated with the client’s use of alcohol and drugs, and the lack of personal care. The employee may also be exposed to bodily fluids (blood, urine) and hazardous chemicals.

WellSpace Health is committed to the principles of equal employment. We are committed to complying with all federal, state, and local laws providing equal employment opportunities, and all other employment laws and regulations. It is the intent of WellSpace Health to maintain a work environment free of harassment, discrimination, or retaliation because of age, race, religious creed, color, national origin, ancestry, physical disability, medical condition, genetic information, marital status, sex (including pregnancy, childbirth, breastfeeding and/or related medical conditions), gender, gender identity, gender expression, sexual orientation, military or veteran status, or any other status protected by federal, state or local laws. WellSpace Health is dedicated to the fulfillment of this policy in regard to all aspects of employment, including but not limited to recruiting, hiring, placement transfer, training, promotion, rates of pay, and other compensation, termination, and all other terms, conditions, and privileges of employment.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

WellSpace Health is an Equal Opportunity Employer

WellSpace's mission is "achieving regional health through high quality comprehensive care." We believe that everyone deserves to be seen, no matter who you are, where you come from, where you work or what place you call home. At WellSpace, we see you!

We are driven to serve the whole person through comprehensive, integrated care, spanning medical, dental, behavioral health, and supportive services across the region. We do this by building a team of exceptional colleagues who are dedicated to our mission and becoming part of the communities we serve.

As the region's largest Community Health System, WellSpace utilizes a Confluence Model to integrate an internal network of healthcare modalities, including Federally Qualified Health Centers (FQHC), Certified Community Behavioral Health Center (CCBHC), Drug Medi-Cal and Specialty Mental Health programs, California's second largest 988 Suicide and Crisis Lifeline Center, an independent Risk Bearing Organization (WellSpace Nexus), and more into a seamless confluence of care.

To ensure the highest quality of care, WellSpace is accredited by the Joint Commission for Ambulatory Care, Behavioral Health and as a CCBHC. Further, it is certified by the Joint Commission as a Primary Care Medical Home and a Behavioral Health Home. WellSpace's crisis programs are accredited by the American Association of Suicidology and the International Council for Helplines.

Company Description

WellSpace's mission is "achieving regional health through high quality comprehensive care." We believe that everyone deserves to be seen, no matter who you are, where you come from, where you work or what place you call home. At WellSpace, we see you! \r\n\r\nWe are driven to serve the whole person through comprehensive, integrated care, spanning medical, dental, behavioral health, and supportive services across the region. We do this by building a team of exceptional colleagues who are dedicated to our mission and becoming part of the communities we serve. \r\n\r\nAs the region's largest Community Health System, WellSpace utilizes a Confluence Model to integrate an internal network of healthcare modalities, including Federally Qualified Health Centers (FQHC), Certified Community Behavioral Health Center (CCBHC), Drug Medi-Cal and Specialty Mental Health programs, California's second largest 988 Suicide and Crisis Lifeline Center, an independent Risk Bearing Organization (WellSpace Nexus), and more into a seamless confluence of care. \r\n\r\nTo ensure the highest quality of care, WellSpace is accredited by the Joint Commission for Ambulatory Care, Behavioral Health and as a CCBHC. Further, it is certified by the Joint Commission as a Primary Care Medical Home and a Behavioral Health Home. WellSpace's crisis programs are accredited by the American Association of Suicidology and the International Council for Helplines.