Position Summary: The Accreditation/ISO Coordinator is a key participant in the hospital's continuous accreditation and regulatory readiness program. Responsible for providing direction and oversight for regulatory and accreditation compliance including DNV, ISO 9001 Quality Mgmt System Requirements, and State and Federal agencies. This individual assists in maintaining preparedness for accreditation and licensure surveys.
Qualifications: EDUCATIONAL REQUIREMENTS Requires Bachelors degree or equivalent in nursing or other healthcare related field. Master's degree preferred.
CERTIFICATION & LICENSURE REQUIREMENTS Certified Professional in Healthcare Quality (CPHQ) within 1 year of employment.
EXPERIENCE REQUIREMENTS Five years of experience in the healthcare industry required with significant experience in clinical operations and/or process improvement. Previous accreditation/regulatory readiness experience preferred.
Conduct gap analyses and develop evidence-based corrective action plans to assure compliance with regulatory standards;
Facilitate monthly accreditation education session to include agenda planning, minutes, and presentations as needed;
Organize an interprofessional team to serve as chapter leads for accreditation standards;
Executes survey readiness program, including mock surveys and tracer methodology preparations;
Provides consultation to organization leaders on survey readiness and NIAHO standards;
Updates leaders on new standards and assures effective communication of expectations;
Assist in assuring accuracy & timeliness in submission of corrective action plans to external agencies and internal stakeholders;
Responsible for developing ISO internal audit strategy and oversight, and implementation of ISO strategic plan.
We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.
Internal Number: 6361
Based in Urbana, IL, The Carle Foundation is a vertically integrated health system with more than 7,000 employees in its hospitals, physician group, health plan and associated healthcare operations. Serving a population of over 1.4 million people across 41 counties in Illinois and five in Indiana, Carle provides patient-focused, world-class care with a dedication to research and education. The 413-bed Carle Foundation Hospital is the region’s only Level I Trauma Center and offers Level III perinatal services. Carle ranked in 2018 as one of America’s 50 Best Hospitals by Healthgrades, a Best Hospital by U.S. News and World Report and has achieved Magnet® designation, the nation’s highest honor for nursing care. In addition, Carle secured Great Places to Work in Healthcare honors in 2018. The system also includes the 24-bed critical-access Carle Hoopeston Regional Health Center, the 134-bed Carle Richland Memorial Hospital, and Carle Physician Group with more than 500 doctors. Carle’s Centers for Excellence include Mills Breast Cancer Institute, Carle Cancer Center, Carle Spine Institute, Carle Neuroscience Institute, Carle Digestive Health Institute and Carle Heart and Vascular Inst...itute. Carle Illinois College of Medicine is the world’s first engineering-based college of medicine. And the Stephens Family Clinical Research Institute enables clinicians and scientists to partner in solving some of today’s most pressing health issues. Part of the Carle system, Health Alliance is a leading provider-driven health plan serving nearly a quarter-million members in Illinois, Iowa, Indiana, Ohio and Washington. In 2017, Health Alliance was awarded by J.D. Power for highest member satisfaction among commercial health plans in the Illinois and Indiana Region.