Accreditation Specialist

Weekend Requirements: As Needed | Work Hours: Variable Hours; Business Need | Status: Part Time - 0.5 FTE (40 hours per pay period) | Entity: Owensboro Health Regional Hospital | Department: Accreditation

Job Summary:

Accreditation Specialists serve as key resources supporting compliance and survey readiness across the Owensboro Health system. They work collaboratively with operational leaders to ensure alignment with accreditation standards, regulatory requirements, and internal policies, promoting continuous readiness and quality improvement at all Owensboro Health facilities.

Job Responsibilities:

• Serves as an expert consultant for staff in one or more of the following areas: accreditation & regulatory compliance, organizational policies, policy management, clinical procedures. Interprets regulatory standards and organizational policies & procedures.

• Assists with and/or coordinates activities, projects, and operational efforts related to accreditation, licensure, and/or certification with critical organization-wide impact, including participation in regulatory site visits/surveys. This may also include assisting with the development and/or implementation of new or revised processes, policies and/or procedures.

• Utilizes and/or maintains related databases/information management systems. Responsible for training, updates, security management, and report generation as applicable to assigned database/information management system.

• Works collaboratively with leadership to plan, facilitate and evaluate multidisciplinary process improvements related to accreditation and regulatory initiatives.

• Facilitates change process through committee participation as needed.

• Utilizes standardized methods for improvement efforts, including project coordination. Also utilizes common concepts for statistical analysis, outcomes measurement, quality improvement tools, systems thinking, and operations improvement practices. Interprets and disseminates related data to stakeholders.

• Reviews and/or develops related content and communicates information to all team members via multiple forms of publication and communication. Develops and implements related staff educational materials as needed.

• Participates in staff orientation and continuing education as assigned.

• Required to travel to off-site locations for participation in accreditation & regulatory-related activities.

Skills and Attributes:

• Requires critical thinking skills and decisive judgment.

• Works under general supervision.

• Must be able to work in a stressful environment and take appropriate action.

• Applies more advanced skills and knowledge in the area of specialization.

Position Requirements:

Work Experience

• A minimum of 3 years' relevant experience required

Education

• Bachelor's degree or higher in Nursing required upon hire OR

• Bachelor's degree or higher in nursing related field required upon hire

Additional Education Information

• A combination of education, training and experience may be considered in lieu of degree.

Licensure/Certification/Registration

• RN - Licensed as a Registered Nurse. Eligible to practice nursing in the State of Kentucky required upon hire OR

• Current licensure in related field required upon hire AND

• Accreditation/Clinical Program related certification preferred      

Organizational Responsibilities:

• Supports Owensboro Health’s Mission, Vision, Core Commitments, and business interests.  Adheres to all organizational policies and procedures. Executes all tasks and behaves in a manner consistent with a culture of compliance, safety and a high reliability organization.

Additional Job Information:

• This job description describes the general nature and level of work required by the position. It is not intended to be an all-inclusive list of qualifications, skills, duties, responsibilities or working conditions of the job. Specific duties and responsibilities consistent with the general nature and level of work described may vary by department and additional related duties may be assigned as needed. Some duties listed may not apply to all employees with this job description. 

• The job description is subject to change with or without notice, and Management reserves the right to add, modify or remove any qualification or duty. Nothing in this job description changes the existing at-will employment relationship between the Organization and the employee occupying the position.

Standard ADA Settings:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Physical Demands: (Office Environment)

Standing: Occasionally

Walking: Occasionally

Sitting: Frequently

Lifting 0-25 lbs.: Rarely

Lifting 25-75 lbs.: Rarely

Lifting over 75 lbs.: Rarely

Carrying 0-25 lbs.: Rarely

Carrying 25-75 lbs.: Rarely

Carrying over 75 lbs.: Rarely

Pushing/Pulling 0-25 lbs.: Frequently

Pushing/Pulling 25-75 lbs.: Rarely

Pushing/Pulling over 75 lbs.: Rarely

Climbing: Rarely

Bending/Stooping: Rarely

Kneeling: Rarely

Crouching/Crawling: Rarely

Reaching: Occasionally

Talking: Frequently

Hearing: Frequently

Repetitive Foot/Leg Movements: Rarely

Repetitive Hand/Arm Movements: Frequently

Keyboard Data Entry: Frequently

Running: Rarely

Vision: Depth Perception: Frequently

Vision: Distinguish Color: Frequently

Vision: Seeing Far: Frequently

Vision: Seeing Near: Frequently

Hazardous Drug Risk Exposure: Low risk

Owensboro Health Core Commitments

INTEGRITY - We conduct ourselves with a high level of responsibility, reliability and honesty because we take seriously the trust of our patients and coworkers.

RESPECT - We value and accept the unique talents and contributions of every patient, customer and team member in the Owensboro Health community.

TEAMWORK - We build a spirit of connectivity and fellowship by striving together to overcome obstacles, surpass goals, celebrate accomplishments and plan the future.

INNOVATION - We foster original ideas and creative solutions that improve our daily work and promote the mission of Owensboro Health.

SERVICE - We focus on service to patients, customers and team members by anticipating their needs, thoughtfully meeting those needs and continually improving the quality of everything we do.

EXCELLENCE - We reach beyond basic expectations to expand our knowledge and awareness, produce exceptional work and provide outstanding service.