Accreditation & Regulatory Consultant - Behavioral Health Focus

Overview:

This position will primarily support Behavioral Health Acute Crisis Services - PCD, YCSU, and Inpatient. This consultant will provide guidance to ensure compliance with Joint Commission Behavioral Health and Hospital standards, as well as Ohio Administrative Code for our licensed inpatient psychiatric units. This role will support BH policy review, development, and revision to align with regulatory and accreditation standards.

Job Description Summary:

Assists in the evaluation, implementation, monitoring, improvement of compliance with internal and external regulatory requirements, and policies for the organization. Works on a multi-disciplinary team and shares best practices among all areas.

Job Description:

Essential Functions:

• Leads and manages surveys and continuous readiness activities.
• Maintains working knowledge of regulatory and accrediting body standards and rules.
• Prepares and presents regulatory updates to Department as requested.
• Partners with hospital management to guide practice and operations with applicable regulations or standards.
• Acts as a consultant to the unit on all matters related to regulatory and accreditation (TJC, CMS, ODH, OMHAS) surveys.
• Partners with unit on development, implementation and monitoring of action plans.
• Leads or collaborates in work groups to build regulations into operations.

Education Requirement:
Bachelor's of Science or work experience in the field equivalent to a bachelors, required. Master's Degree, preferred.

Licensure Requirement:
(not specified)

Certifications:
Certified Professional in Healthcare Quality, (CPHQ), certification, preferred.

Skills:
Demonstrated planning, presentation, and project management skills required. Strong skill in promoting multidisciplinary collaboration.

Experience:
2 years working in a hospital and experience with survey readiness and accreditation related activities.

Physical Requirements:
OCCASIONALLY: Biohazard waste, Chemicals/Medications, Climb stairs/ladder, Cold Temperatures, Fume /Gases /Vapors, Hot Temperatures, Loud Noises, Patient Equipment, Pushing / Pulling: 0-25 lbs, Working at Heights

FREQUENTLY: Bend/twist, Driving motor vehicles (work required) *additional testing may be required, Hand use: grasping, gripping, turning, Lifting / Carrying: 11-20 lbs, Reaching above shoulder, Sitting, Squat/kneel, Standing, Walking

CONTINUOUSLY: Audible speech, Color vision, Computer skills, Decision Making, Depth perception, Flexing/extending of neck, Hearing acuity, Interpreting Data, Lifting / Carrying: 0-10 lbs, Peripheral vision, Problem solving, Repetitive hand/arm use, Seeing - Far/near

Additional Physical Requirements performed but not listed above:
High stressful Environment

"The above list of duties is intended to describe the general nature and level of work performed by individuals assigned to this classification. It is not to be construed as an exhaustive list of duties performed by the individuals so classified, nor is it intended to limit or modify the right of any supervisor to assign, direct, and control the work of employees under their supervision. EOE M/F/Disability/Vet"