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  • Charleston, WV
  • Posted: February 17, 2020
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  • Basic Description
    • Responsible for accrediting body information and services for CAMC and CAMCHSI. General areas of responsibility include: serves as consultant to administration, medical staff, clinical support services, nursing and support services on interpretation of accrediting body standards including development of strategies to meet the intent of the standards; establishment and maintenance of a comprehensive system to identify, evaluate, and prevent or minimize areas of noncompliance with accrediting body standards; mobilization of resources to address areas of noncompliance and monitor results of actions taken; coordinating of accrediting body functions among administration, medical staff, professional nursing, clinical support services, and other areas of the institution impacted by accrediting body standards; establishment and maintenance of a comprehensive system for communication to all levels of the organization upon unannounced arrival of accrediting body Survey or for hospital and laboratory point-of-care surveys; establishment and leadership responsibility for the accrediting body Command Center during on-site visits; resource to V.P. for Disease Specific Specializations (DSS) from accrediting body. Serve as chairperson of accrediting body Steering Committee and participation and/or facilitation of the accrediting body Core Team and Executive Steering Team in absence of the V.P. Liaison with accrediting body on all matters relating to accreditation.
  • Specialized Knowledge, Experience and Skills
    (Education, Experience and Skills required to fully perform the requirements of the position)
    • Degree / Education
      • Masters Degree - Nursing
    • Level of Experience
      • 5 - 7 Years - Healthcare System 
    • Lic./Cert./Reg.
      • All licensure must be current/valid and from the state of West Virginia.
      • Registered Nurse
    • Typing/Word Processing skills required for this position
    • Computer Skills required for this position
      • Word Processing/Spreadsheets/Accrediting Body Related Softwares.
      • Basic PC Skills
    • Other Required Areas of Knowledge, Skills and Abilities
      • Analytical Skills
      • Applies Knowledge To New Situations
      • Bookkeeping
      • Community Resource Knowledge
      • Customer Service
      • Decision Making
      • Employee Relations
      • Flexible Schedule
      • Handle Multiple Assignments
      • Judgment
      • Organization
      • Problem Solving
      • Project Management
      • Public Speaking
      • Supervisory Skills
      • Teamwork
      • Verbal Communication
      • Work Independently
      • Written Communication
    • Acceptable SUBSTITUTIONS (if any)
    • Patient Group Knowledge (Only applies to positions with direct patient contact)
      • The employee must possess/obtain (by the end of the orientation period) and demonstrate the knowledge and skills necessary to provide developmentally appropriate assessment, treatment or care as defined by the department’s identified patient ages. Specifically the employee must be able to demonstrate competency in: 1) ability to obtain and interpret information in terms of patient needs; 2) knowledge of growth and development; and 3) understanding of the range of treatment needed by the patients.
    • Assigns work to or supervises others
    • Competency Statement
      • Must demonstrate competency through an initial orientation and ongoing competency validation to independently perform tasks and additional duties as specified in the job description and the unit/department specific competency checklist.
    • Minimum Requirement Comments
      • Knowledge of accrediting body standards and survey process, hospital/clinical issues and healthcare delivery system. Knowledge of legislative and regulatory requirements related to hospital accreditation. Knowledge of and experience with techniques of data and information management. Knowledge of study methodology and design in continuous quality improvement. Ability to recognize and protect confidential information.
  • Physical Requirements
    (Essential physical requirements)
      • Vision
      • Hand Coordination
      • Arm Coordination
      • Hearing
      • Crouching/Stooping
    • Activities Requiring Time
      • Sitting - 7 hr
      • Standing - 1 hr
      • Walking - 4 hr
    • Lifting
      • Up to 10 lbs - Seldom
      • 11 to 24 lbs - Seldom
    • Pushing
    • Reaching / Pulling

Job Information

Req #: 20840-17438