Accreditation Coordinator

Schedule: Monday to Friday full-time days

Something special starts here.

You can’t define it, but you know it when you see it: the difference between an average life and the good life. When your cup is full – with joy, purpose and lifelong health – it shows. At LMH Health, we are all about healthy people, healthy communities and healthy futures, and that makes us your destination for an exceptional career. From flexible, work-life harmony to competitive pay and great advancement potential, find everything you’re looking for at LMH Health.

You'll find everything you’re looking for at LMH Health:

• Join a team that cares about the community
• Tuition reimbursement to support continuing education
• Professional development and recognition
• Excellent benefits

We’re looking for you.

As the Accreditation Coordinator you will plan, coordinate and monitor compliance with national standards. LMH Health has multiple accreditations through The Joint Commission and the American College of Surgeons. You will partner with leaders throughout the system to manage accreditation activities necessary for maintaining accreditations. You will assist with ensuring full compliance with accreditation/regulatory policies and standards, develop continuous process improvement strategies to address any performance gaps, and streamline workflows across respective accreditation/regulatory program activities.

Responsibilities

1. Reviews and understands all standards relevant for accreditation programs.
2. Coordinates accreditation/regulatory meeting schedules, agendas, preparation of materials, and meeting minute documentation.
3. Coordinates other accreditation committee activities including coordinating speakers, documenting compliance, and required applications and reports.
4. Tracks adherence to and progress against established standards.
5. Assists with completing the survey administration records.
6. Prepares for and facilitates on-site surveys.
7. Identifies opportunities to utilize Operational Excellence in processes relating to TJC standards and CMS CoP.
8. Work with organizational stakeholders to provide required data and related analysis for standards compliance, planning, and quality initiatives.
9. Works collectively with team leadership to follow up on any findings or post-survey activities to address items.
10. Formulate and convene work teams to address accreditation standard or quality improvement project needs.
11. Participates with the accreditation team to support other projects as assigned.

Successful candidate will have:

-         Advanced knowledge of computer spreadsheets and databases.

-         Basic knowledge of statistics and statistical methods of analysis.

-         Good organizational skills; ability to prioritize, use good time management and adhere to deadlines as directed.

-         Strong and collaborative team player; works well in a continuous learning environment. 

-         Advanced interpersonal skills including clear and effective communication (both written and verbal) with diverse audiences.

-         Strong listening skills and the ability to problem solve and make informed decisions.

Qualifications

Required:

• Bachelor’s degree in a healthcare-related field (e.g. nursing, healthcare administration, public health, etc).             
• 2 years of experience in accreditation, process improvement, quality management and/or project management in a clinical environment.

Preferred:

• Experience in clinical environment (preferably oncology).
• Master’s degree.
• Yellow Belt, Lean Six Sigma, or advanced.
• 5+ years of experience in project management and/or accreditation.

Our Cultural Beliefs

Patient First. We consider the patient first in everything we do.

Better Together. We actively strive to be a diverse LMH Health team that works together to achieve excellence.

Listen/Speak Up. We embrace a diverse culture of open, respectful, well-intended communication where we listen, share, and value ideas to create equitable solutions.

Innovate! We actively explore new ideas and approach change with agility and an open mind.

Own It/Solve It. We hold ourselves accountable for our actions and we collaborate for solutions.

In Joy. We create a workplace that is both fun and meaningful.