Description

GENERAL RESPONSIBILITIES: The Accreditation Advisor is an active surveyor who provides accreditation support to facilities and surveyors. The person in this position will be responsible for conducting 2 surveys a month and for managing the corrective action plan process.  The Accreditation Advisor will be an active participant in the review of facility reports, review of corrective actions added to the report, tracking and monitoring of corrective action plans submitted to NCCHC for review and approval of each item submitted.  The Accreditation Advisor will manage the day-to-day activities related to the corrective action process and provide support to facilities throughout the corrective action response process.  The Accreditation Advisor will be the liaison between NCCHC and each facility who has corrective action to submit and/or has submitted. Performance in this job is measured through the success of activities focused on accreditation; quality of surveys conducted, quality of decisions related to approval of corrective action plans, as well as feedback from clients and surveyors. Remote work considered for exceptional candidates. 

RESPONSIBILITIES:

 ACTIVE SURVEYOR

•       Conducts two surveys per month throughout the United States within the full scope of the Standards to maintain expert skills and knowledge and build relationships with the surveyors
•       When in the General Surveyor role, conducts a thorough and credible evaluation of assigned activities by the Lead
•       When in the Lead Surveyor role, prepares facility reports within 1 week of survey and submits via designated email 
•       Engages facility staff in interactive conversations on the standards in an effort to assess compliance and to identify opportunities for improving compliance 
•       Clearly communicates the standards deficiencies and potential system vulnerabilities and facility risk points to the Lead and when in Lead role, clearly communicates these findings during the exit conference

FACILITY REPORT MANAGEMENT

•       Works with Accreditation Coordinator to review facility survey reports and to help clarify ambiguities/missing information with lead surveyor, as requested by Accreditation Coordinator
•       In conjunction with the Accreditation Coordinator, maintains accuracy of corrective action  data on the Post-Survey activity tracking tools utilized internally by the Accreditation Team, attending meetings to discuss these tools as assigned

CORRECTIVE ACTION MANAGEMENT AND FACILITY SUPPORT

•       Manages day-to-day corrective action process to include:
  • Tracking receipt of corrective action plan from facility
  • Initiates review of materials
  • Approves materials
  • Notifies Accreditation Coordinator assigned to sending certificates or adds to NCCHC Accreditation Committee Agenda
•       Updates tracking spreadsheet and monitors timelines
•       Coaches facilities through the post-survey process when a corrective action plan is required 
•       Works with Director of Accreditation and Manager of Accreditation on any corrective action compliance concerns 
•       Meets with Director of Accreditation at designated intervals to review pending Corrective Action and outstanding facility needs

 CLIENT SUPPORT 

•       Attends NCCHC national conferences and attends/participates in surveyor meetings/trainings
•       Supports facility staff by answering general questions from the field timely 
•       Attend several surveys per year, as needed, in a Mentor/QI observation role and provide support to new surveyors 

GENERAL

•       Participate in monthly all department staff meetings and Accreditation department staff meetings
•       Other duties as assigned  
•       As requested by Accreditation Leadership Team, develops, implements, evaluates, and enhances survey tools for use by survey teams
•       As requested by Accreditation Leadership Team, regularly updates all surveyor documents such as handbooks, worksheets, tools, and/or forms

 SURVEYOR TRAINING

•       Participate in accreditation standards training for surveyors
•       As requested, participates in training for new and active surveyors, as well as for each survey group- lead, physician, and general surveyor 

 COMMITTEE PARTICIPATION

•       As requested, participate in the Surveyor Advisory Committee (SAC) and Accreditation Committee meetings

Requirements

MINIMUM QUALIFICATIONS:  

      Bachelor's Degree or equivalent practical experience. Master’s Degree a plus.

      CCHP certification required. Must obtain within one year of hire if not a CCHP upon hire.

      3-5 years of recent experience in corrections

      2 plus years’ experience with quality improvement plans and/or plan of correction 

      A background in health, public health, or accreditation bodies a plus

      Experience supervising, training, and planning

      Extensive knowledge regarding NCCHC standards including the application and interpretation in a variety of settings a plus

KNOWLEDGE, SKILLS, AND ABILITIES:    

      Ability to read and understand materials concerning health care in criminal justice and law enforcement agencies

      Knowledge of health care systems in correctional institutions

      Exemplary writing and speaking skills

      Ability to work independently and solve problems involving complex variables

      Ability to organize, plan, and implement strategic and operational plans 

      Ability to deal tactfully, professionally, and effectively with others

      Ability to make decisions based on experience, giving attention to details

      Intermediate to advanced proficiency in Word, Excel, Outlook, PowerPoint, and general proficiency with Salesforce

      Ability to travel is required, may be as frequent as 1-2 times per month to conduct 2*3 surveys each month

      Remote work considered for exceptional candidates