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Role Description

Provides interpretation of all Joint Commission standards with special emphasis on standards issues related to specific settings, including home care, nursing care center, and assisted living community, professional disciplines, or accreditation/certification programs. Combines systems analysis skills with in-depth general and program-specific knowledge to evaluate health care organizations’ compliance and ability to provide high quality, safe patient care. Participates as a partner in the development and revision of standards and survey/review process. Participates in ongoing accreditation/certification services and special projects. Serves as faculty for surveyor and other education programs and represents the Joint Commission as liaison to various professional organizations. In conjunction with operations team, ensures that accredited/certified organizations receive excellent customer service and that their accreditation/certification needs are met.

Responsibilities

• Supports accreditation and certification by developing, reviewing, and analyzing survey reports and outcomes, and engaging with field representatives and organizations.
• Analyzes reports for accuracy and recommends accreditation and certification decisions.
• Evaluates clarifications and evidence of standards compliance, making final determinations.
• Collaborates in real-time with field staff during survey and review activities as assigned.
• Offers expert analysis and advisory support on Joint Commission standards and Medicare requirements, professional standards of practice, and law and regulation to internal and external customers.
• Delivers education and guidance on standards, while communicating emerging healthcare trends, leading practices, and newly identified issues to support corrective actions and effective use of Joint Commission tools.
• Partners with program development staff to ensure program interpretations reflect regulatory expectations and national standards of practice, helping to balance accreditation demands with quality and safety goals.
• Provides support to OQPS in complaint analysis through complaint review, identification of potential non-compliance, development of assessment tools for surveyors, and participation in preparatory discussions. Schedules and conducts real-time review calls with on-site surveyor for urgent/PL 1 For Cause surveys.
• Provides leadership and guidance to the Accreditation and Certification Operations (ACO) service teams in all aspects of the accreditation process through clinical expertise and customer relationship management.
• Serves as a role model in the support of and implementation of enterprise, division and departmental mission and initiatives utilizing Robust Process Improvement (RPI) tools and strategies as indicated. Leads or participates in internal work groups to identify and implement improvements to internal processes.
• Provides direction and guidance to internal and external customers in the consistency of standards interpretation through inquiry and frequently asked questions (FAQ) management processes, educational offerings, publications and media and social networking opportunities. Serves as faculty for field representative training (both JC and JCR), Speaker’s Bureau and JCR seminars and workshops. Participates in strategic teams or other program specific committees and work groups, as assigned.
• Communicates professionally and collaboratively with internal and external stakeholders, ensuring a respectful and constructive approach while consistently delivering exceptional customer service.
• Demonstrates commitment to the Joint Commission’s safety culture by integrating Department Guidelines into everyday practices and professional interactions.
• Provides training and guidance on Joint Commission accreditation and certification programs for existing and prospective organizations.
• Contributes to departmental quality assurance initiatives to maintain accuracy and consistency in processes and outcomes.
• Participates and presents memos for accreditation decisions to the Accreditation Council, providing background on accreditation decision requests and answering questions.

Qualifications

• Healthcare clinician with master’s degree (or actively working on it) with a minimum of five years of leadership experience.
• Demonstrated analytical, inductive and deductive reasoning skills.
• Demonstrated excellent customer relationship management skills.
• Demonstrated positive peer and leadership relationships.
• Interpersonal skills to interact effectively with individuals at various levels both inside and outside of the organization, often in sensitive situations.
• Strong writing and speaking skills.
• Demonstrated ability to function well in a fast-paced, highly visible and challenging environment.
• Demonstrated ability to problem solve and manage multiple priorities meeting and/or exceeding customer expectations with regards to turn around time and quality of the response/interaction.
• Strong computer skills preferred including word processing, presentation software and databases.
• Must be able to lift 25 pounds.
• Must be able to climb stairs and ladders and work in settings with infectious diseases.
• Must be able to travel up to 20% of work time.