Accreditation Coordinator

Job Description

Job Description

This position is responsible for the quality assurance functions of program operations. This position ensures compliance with all accreditation, licensure, and contractual obligations of agency programs.

• Have full working knowledge of accreditation and licensure standards required of programs including but not limited to CARF(Commission on Accreditation of Rehabilitation Facilities), ACA ( American Correctional Association), and DBHIDS licensing standards.
• Ensure the facilitation of the accreditation process including communications with the accreditation body via the Quality Assurance Director and establishing a quarterly scheduled meeting with program staff to meet accreditation deadlines.
• Submit recommendations to the Quality Assurance Director regarding policy and procedures in accordance with accreditation standards, licensure requirements, contract obligations, or changes in law.
• Assist the QA Director with all aspects of the accreditation process, including but not limited to, scheduling site visits, developing teams for pertinent committees, preparing materials, editing reports, maintaining records/files, and responding to inquiries.
• Ensure adherence to accreditation standards, licensure requirements, contract obligations, or changes in law by following the quality assurance plan approved by the respective Vice Presidents, Quality Assurance Director, and COO.
• Evaluate submission documentation for compliance with established standards as well as consultative guidance and feedback with respect to the application of standards at the practical level in the agency.
• Submit a summary of documentation/physical site review and corrective action plan to the Quality Assurance Director for approval.
• Develop and maintain a compliance calendar for managers for staff credentials, required training, and clearances.
• Ensure the agency meets HIPAA compliance regulations.
• Conduct monthly New Employee orientation trainings as needed to support program management maintaining compliance with training requirements.
• Chair Health and Safety Committee which involves facilitating meetings and conducting monthly inspections to ensure organization-wide compliance with Health and Safety standards providing a report on all identified concerns and corrective action plans to the Risk Management Committee
• Operate as a liaison working with Foodservice contract providers and programs ensuring that all clients receive high-quality food and satisfactory food service. Observe meal delivery and service at a program monthly.
• Coordinate satisfaction surveys for clients, staff, and stakeholders
• Aggregate data from all programs for the annual National Program service summary report.
• Interact (verbally and non-verbally) with all clients, staff, and community members with respect and courtesy.
• Attend and participate in regularly scheduled staff meetings, supervisory conferences training sessions, and meetings as required.
• Maintain client and staff confidentiality in compliance with Administrative Policies and Procedures and Operational Policies and Procedures.
• Other duties as assigned.