Accreditation Regulatory Specialist

  • Lake County, IL
  • Waukegan, Illinois
  • Nov 06, 2019
Full Time Regulatory and Licensing

Job Description

Do you want a career where you can truly make a difference? The Lake County Health Department and Community Health Center is one of the largest human service providers in Lake County. We live our mission each day, promoting the health and well-being of all who live, work, and play in Lake County. If you are passionate about giving back and ready to be a part of an innovative team, we are looking for you!

About the Role:

The Accreditation Regulatory Specialist is responsible for leading and coordinating activities required for successful accreditation, licensing and certification. This includes responsibility for developing and implementing systems and processes to sustain readiness for Joint Commission (TJC),Substance Abuse and Mental Health Services Administration (SAMHSA)Health Resources and Services Administration (HRSA), Illinois Department of Human Services (DHS) Illinois, Department of Healthcare and Family Services (HFS), Illinois Department of Mental Health (DMH), Illinois Division of Substance Use Prevention and Recovery (DASA), Illinois Department of Public Health (IDPH) and the Centers for Medicare and Medicaid (CMS), and others. Utilizes leadership, project coordination, and facilitation skills to set clear expectations, bring diverse team members to consensus and achieve desired results. Establishes quantitative measurement systems and transfers change management and performance improvement skills and knowledge to ensure ongoing operational improvement.

Location: 3010 Grand Avenue, Waukegan IL

Hours: Monday- Friday (8:30am - 5:30pm)


Skills and Experience

  • Provide leadership and coordination for the organization, to maintain compliance with TJC, SAMHSA, HRSA, DHS, HFS, DMH, DASA, IDPH, CMS. and other quality of care accreditation and regulatory standards.
  • Provide leadership to operational efforts related to accreditation, licensing or certification that have critical organization wide impact. This may include assisting with the development/implementation of new or revised processes, information technology solutions, and policies and/or procedures. Works collaboratively with leadership to plan, facilitate and evaluate multidisciplinary process improvements relating to accreditation or regulatory initiatives.
  • Serve as a contact and resource for accrediting and licensing organizations. Leads change process through committee leadership/membership as needed. Utilizes standardized methods for improvement efforts, including Rapid Improvement methods and project coordination. Also utilizes common concepts for statistical analysis, outcomes measurement, quality improvement tools, systems thinking, and operations improvement practices.
  • Develops content and communicates accreditation/regulatory related activities and information to all staff via newsletters or other forms of publications and communication. Develops and implements staff education materials and forums related to this information, activity and processes.
  • Develops and implements methods for ongoing review to assess the level of site visit/ survey readiness. Conducts prospective, concurrent and retrospective studies using a sound clinical and/or healthcare knowledge base and statistical analysis skills to support policy, procedure and system change. Facilitates groups to assist in root cause analysis, Failure Modes Effect Analysis (FMEA) or other process improvement activities as required.
  • Creates and maintains a calendar/schedule of required and recommended activities for accreditation and licensure activities and milestones, and monitors for compliance.
  • Maintains and monitors portal access and information related for communicating regulations or compliance to standards.
  • Develops and maintains a working knowledge of individual Emergency Preparedness roles.
  • Participates in mandatory in-services and drills, attends staff meetings and other trainings offered on a regular basis for professional development.
  • Prepares reports necessary for operation of accreditation preparedness functions. Provides direction on the evaluation of clinical and administrative programming that is offered utilizing published best practices and empirically proven clinical methodologies in delivery of client care.
  • Reports all unusual occurrences that may involve the safety and well-being of the patients and co-workers, directly to supervisor and/or Safety Officer.
  • Lead the biennial Intracycle Monitoring activities for the Joint Commission Behavioral Health and Methadone standards, including creating and monitoring action plans to address gaps in compliance.
  • Other duties as assigned

Education, Qualifications, and Certification:

  • Bachelor's Degree required. Master's level preparation strongly preferred.
  • Associate's degree in clinical area plus two years related experience may be considered in lieu of Bachelor's degree.
  • Requires 3-5 years' experience and knowledge of regulatory and accrediting standards.
  • Experience with behavioral health standards highly desirable.

About the Perks:

Lake County offers a competitive salary and benefit package with performance-based incentive plans. We also offer flexible working hours, and a comprehensive wellness and training program. Visit the Health Department page to get additional information on why you should work for us.

If you would like to learn more about our community impact and to see some of our employees in action, please review this short video.

Any offer of employment is conditioned on the successful completion of a background screening, drug and alcohol testing and may include a pre-employment medical exam.

The Lake County Health Department and Community Health Center is an Equal Opportunity Employer.

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