Accreditation and Compliance Specialist II

Job Description

Summary

*This is a MaineHealth job specifically working in Maine Behavioral Healthcare
Position Summary

As part of a team the duties will include the coordination of: both hospital and behavioral health accreditation standards; State of Maine agency licensing updates; and companywide policy coordination.

The Accreditation and Compliance Specialist II will assist leaders and managers in assessing adherence to accreditation and licensing standards, support efforts to improve and maintain adherence to standards by providing reports to highlight gaps and helping develop action plans as appropriate. The Accreditation and Compliance Specialist II will organize mock surveys and readiness audits, help maintain an up-to-date Quality Assurance and Performance Improvement (QAPI) plan, coordinate activities during surveys, maintain relevant information on file and readily accessible during surveys, communicate results after accreditation surveys, help draft and submit a plan of correction, and lead inter-professional teams in addressing survey deficiencies.

**Familiarity with The Joint Commission, CMS and State accreditation standards strongly preferred**
Required Minimum Knowledge, Skills, and Abilities (KSAs)
Education: Associate’s degree with at least five years of relevant healthcare experience OR bachelor’s degree with at least three years of relevant healthcare experience required.
License/Certifications: N/A
Experience: See “Education.” Experience working with inter-professional teams in addressing organization-wide problems.
Familiarity with The Joint Commission, CMS and State accreditation standards required
Familiarity with performance improvement tools and concepts, e.g., plan-do-study-act, preferred
Proficiency in Microsoft Office suite or equivalent preferred
Familiarity with electronic health records preferred
Effective verbal and written communication skills
Strong critical thinking skills and attention to detail
Collaborative and team oriented

Additional Information

MaineHealth is a health system whose members and affiliates include hospitals, physician practices, long-term care facilities, home care agencies, and support services. Learn more about this system at www.mainehealth.org