a. state and federal standards and regulations
          b. education and guidance documents

2. Develop knowledge of regulatory and accrediting requirements (e.g., TJC, ODH, ODMHAS, CLIA, OSHA, CMS).

3. Assist in analysis of compliance with standards/regulations as they relate to varying sets of circumstances and recommend compliance strategies.

4. Participate in regulatory surveys.

5. Assist in the development of accreditation/regulatory readiness activities throughout the organization, by, at a minimum:

          a. Acting as liaison between Accreditation Department and organization managers/staff in order to identify compliance challenges/vulnerabilities.

          b. Participating in and/or lead mock surveys.

          c. Developing and/or providing education related to the identification of standards and their applicability to areas and/or operations, as well as          

              compliance trends/strategies.

          d. Assisting with workflow, policy and procedure review/revision related to standards compliance.

         e. Identifying vulnerabilities and providing recommendations for improvement based on analysis of compliance/risk assessments, evidence-based practices, and survey findings.

          f. Assisting with action planning for standards compliance.

6. Demonstrate high level attention to detail.

7. Create and deliver PowerPoint presentations and other educational resources focused on regulatory requirements and departmental and organizational compliance.

8.  Participate in reviewing and updating hospital policies to ensure compliance with regulatory requirements.

9.  Manage confidential information and/or issues using discretion and judgment.

10. Use data tracking, compliance auditing and monitoring tools.

11. Assist with development/maintenance of supporting documents for survey.

12. Travel to off-site locations to assist with Accreditation Department activities.

13. Participate on committees as assigned.

14. Other projects/duties as assigned.

1. Health care experience is required.
2. Excellent interpersonal and communication skills. Ability to effectively collaborate with multiple stakeholders.
3. Experience in regulatory compliance/regulatory surveys preferred.
4. Experience working with all levels of staff in the organization is preferred.
5. Proficiency in MS Office [Outlook, Excel, Word] or similar software is required. Knowledge of clinical documentation systems [EPIC, Midas] is preferred.

Education and Experience

1. Education:

          a. Bachelor's degree in nursing, active Registered Nurse licensure and BLS certification is required.

          b. Master's degree is preferred.

2. Certification is required within three (3) years of hire: Healthcare Accreditation Certification Program (HACP), Certified Joint Commission Professional (CJCP), or equivalent.

3. Years of relevant experience: a minimum of three (3) years in healthcare is preferred.