Accreditation and Governance Specialist

Centerstone is among the nations leading nonprofit behavioral health systems with thousands of employees dedicated to delivering care that changes peoples lives. A dynamic well-established organization we offer rewarding opportunities to serve all ages in a variety of settings. Come talk to us about joining the Centerstone team!

JOB DESCRIPTION:

Position Summary

The Accreditation and Governance Specialist supports Centerstones enterprise Accreditation & Quality Governance program by promoting continuous survey readiness regulatory compliance and consistent implementation of accreditation standards across all markets and service lines.

This position partners closely with operational leaders to interpret accreditation standards conduct mock surveys and tracers monitor corrective action plans and prepare the organization for regulatory and accreditation surveys.

The Accreditation and Governance Specialist serves as a subject matter resource on accreditation requirements and collaborates with Clinical Excellence Clinical Risk Management Patient Voice & Experience and Policy Governance to strengthen organizational quality and regulatory compliance.

Essential Duties and Responsibilities

• Support enterprise accreditation readiness initiatives across all Centerstone markets and service lines.
• Conduct mock surveys tracers and readiness assessments to evaluate compliance with accreditation standards and organizational policies.
• Partner with operational leaders to identify opportunities for improvement and strengthen continuous survey readiness.
• Assist with preparation for accreditation and regulatory surveys including document review evidence collection and survey logistics.
• Monitor compliance with accreditation standards and communicate identified risks or deficiencies to leadership.
• Assist in developing and monitoring corrective action plans resulting from accreditation surveys mock surveys tracers and regulatory reviews.
• Collaborate with operational leaders to ensure timely completion of corrective actions and ongoing compliance activities.
• Provide education and consultation regarding accreditation standards regulatory expectations and survey readiness.
• Assist with interpretation of accreditation standards and communicate updates to operational leaders.
• Participate in enterprise readiness committees and quality governance activities.
• Collaborate with Policy Governance to ensure policies and procedures align with accreditation standards and regulatory requirements.
• Collaborate with Clinical Excellence to incorporate findings from chart reviews tracers and clinical quality evaluations into survey readiness efforts.
• Collaborate with Operations/Clinical management to identify trends that may impact accreditation readiness or regulatory compliance.
• Completes activities associated to SAMSHA survey
• Completes activities necessary to ensure certification of Centerstone locations in National Health Services Corps (NHSC) and the opportunity for enrollment of Centerstone staff into NHSC programs
• Assists in activities to ensure compliance with Federal Rule 1557 of Affordable Care Act regarding non-discrimination activities.
• Maintain documentation and records related to accreditation readiness activities.
• Participate in enterprise quality improvement initiatives as assigned.
• Represents the department on internal organizational committees and functions. Acts as a representative of Centerstone externally with key stakeholders relevant to work of the department.
• Periodic travel may be required to support organizational priorities including leadership collaboration incident response activities staff development and other Clinical Risk Management initiatives. Travel expectations will vary based on organizational needs.
• Perform other duties as assigned.

Supervisory Responsibilities

This position does not have supervisory responsibilities.

Knowledge Skills and Abilities

• Working knowledge of healthcare accreditation standards and survey processes.
• Knowledge of behavioral healthcare operations preferred.
• Knowledge of continuous survey readiness principles.
• Ability to interpret regulatory and accreditation requirements.
• Strong organizational and project management skills.
• Excellent written and verbal communication skills.
• Strong facilitation and relationship-building abilities.
• Strong attention to detail.
• Ability to prioritize multiple projects and deadlines.
• Ability to analyze compliance gaps and recommend practical solutions.
• Proficiency with Microsoft Office applications and electronic documentation systems.

Minimum Qualifications

Education

Bachelors degree in Social Work Health and Human Services Healthcare Administration Nursing Public Health or a related field.

Experience

• Three (3) years of experience in healthcare quality accreditation compliance clinical operations or related healthcare field.
• Experience participating in accreditation surveys mock surveys regulatory reviews or quality improvement activities preferred.

Licenses and Certifications

Preferred:

• Certified Professional in Healthcare Quality (CPHQ)
• Licensed healthcare professional preferred when applicable

Preferred Qualifications

• Experience in behavioral healthcare.
• Experience within a large multi-site or multistate healthcare organization.
• Experience supporting Joint Commission CARF CMS or state licensing surveys.
• Experience conducting mock surveys or tracer activities.
• Experience interpreting accreditation standards and regulatory requirements.
• Experience collaborating with interdisciplinary operational teams.
• Experience developing or monitoring corrective action plans.

Physical and Work Environment Requirements

Work is performed in an office clinical residential and/or community-based environment depending on role and assignment. The position may involve routine use of office clinical or electronic systems and equipment. Duties may require prolonged periods of sitting standing walking and working at a computer. Work hours may include evenings weekends holidays or extended shifts based on program needs. This position is classified as sedentary work. Sedentary work involves exerting up to 10 pounds of force occasionally and/or a negligible amount of force frequently to lift carry push pull or otherwise move objects. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the position.

Program and State-Specific Requirements (When Applicable)

N/A

Disclaimer

The statements herein are intended to describe the general nature and level of work performed by individuals assigned to this position. They are not intended to be an exhaustive list of all responsibilities duties and skills required. Duties and responsibilities may change at any time with or without notice.

Time Type:

Pay Range:

Delivering care that changes peoples lives starts with our employees. Below are just some of the great benefits Centerstone employees enjoy:

• Medical dental and vision health coverage

• Flexible Spending and Health Savings Accounts

• 403b retirement plan with company match

• Paid time off and ten paid holidays

• AD&D Insurance Life Insurance and Long Term Disability (company paid)

• Employee Resource Groups

• Continuing education opportunities

• Employee Assistance Program

Centerstone is an equal opportunity employer. Employment at Centerstone is based solely on a persons merit and qualifications directly related to professional competence. We treat all clients and colleagues with dignity and respect.

At Centerstone we use our values as a guide for what we do. Respect Expertise Integrity and Empowerment are at the heart of every interaction at Centerstone and particularly rooted in our Culture.

Our approach to culture is to create an environment that encourages supports and celebrates the voices and experiences of our employees. We are committed to a culture of empowerment respect integrity and expertise that powers our innovation and connects us to each other our clients and the communities we serve.

Centerstone is also committed to a strong culture of quality and safety celebrating role-models who champion best practices for quality clinical risk and patient safety.

Required Experience:

IC