Job Overview

Employment Type:

Full time

Shift:

Description:

50% time in Dubuque and 50% time in Clinton

POSITION PURPOSE

The purpose of the Coordinator of Accreditation is to coordinate in collaboration with the manager or the RHM director (in the absence of the manager) in leading, implementing and managing systems and processes related to accreditation at the ministry level that ensures regulatory compliance and enhances patient safety. 

The coordinator partners with the health care team across the continuum of care in coordinating regulatory compliance and activities and serves as a resource in the area of Centers for Medicare and Medicaid Services (CMS), The Joint Commission (TJC) and other regulatory agencies.  

The coordinator collaborates with local leadership (President, Chief Operating Officer (COO), Chief Nursing Officer (CNO), and Chief Medical Officer (CMO)) in ensuring effective implementation and support of the accreditation program and compliance.  

SCOPE OF SERVICE

Customers include, but not limited to, patients and families/significant others; medical staff; hospital and clinic colleagues; Executive Team; Board of Trustees/Directors; Trinity Health (TH) Director of Accreditation and Regulatory; TH and MercyOne Integrity, Compliance, and Privacy Services; visitors; attorneys; and government entities.

The coordinator reports directly to the ministry’s Manager of Accreditation; or the RHM Director of Accreditation and Risk Management (in the absence of the Manager) with an indirect reporting relationship to the local CMO.

MINIMUM QUALIFICATIONS

1.    Education:

• A.    Bachelor’s degree in nursing, health administration or related field required.
• B.    Iowa licensure as Registered Nurse preferred. 

2.    Experience:

• A.    More than 3 years’ experience in a health care setting.  
• B.    Regulatory, CPHQ and/or performance improvement experience desired.
• C.    Leadership experience in clinical and professional practice is preferred. 
• D.  Excellent written and verbal communication skills. Must be effective in presenting information to different audiences including senior management, governance, medical staff and associates. 
• E.  Must be proficient in use of Microsoft Excel, Word, PowerPoint, and the Internet.. 

3.    Special Skills, Competencies, and Aptitudes:

• A.    Demonstrated expertise in the use of performance improvement methodology/tools.
• B.    Must be able to use computers for documentation and other relevant activities. Demonstrates specific knowledge related to software programs such as event reporting systems, electronic medical record and other appropriate software programs. Experience with computer applications such as Microsoft Office Suite (Word, Excel, PowerPoint, Outlook), HealthStream, Intranet, and use of reporting tools. Helpful to have experience with PowerChart or similar tool.
   

Our Commitment to Diversity and Inclusion
 

Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by law.