Current Career Opportunities at Oaklawn

JOB SUMMARY:  Responsible for the coordination, integration and maintenance of the overall regulatory and accreditation and infection prevention programs of the Oaklawn enterprise licensure (hospital and ambulatory practice sites). 

ESSENTIAL FUNCTIONS:

• Consistently uses an outward mindset and puts forth exemplary effort in accomplishing his/her goals and objectives in a manner that helps others to achieve their goals and objectives.
• Serves as subject matter expert and internal consultant for regulatory, compliance and accreditation standards and acts as resource for internal as well as external stakeholders.
• Functions as an expert for DNV/ISO, CMS and NIAHO standards for staff.
• Assures the adherence of all standards and policies as set forth by Oaklawn Hospital and the accrediting bodies for the purposes of licensure, regulation and accreditation.
• Facilitates all aspects of the accreditation survey process, including support of mock survey and educational initiatives, to assure staff and organization are continuously prepared and following regulatory guidelines.
• Ensures successful coordination of all primary and specialty program certifications and accreditations as well as individual hospital services in collaboration with administrative and clinical leadership.  
• Chairs appropriate leadership teams, departmental and organizational committees as indicated. 
• Manages the document control and internal audit system to ensure the availability of a well-developed, efficient process that assists in maintaining the Quality Management System.
• Oversees the organization, maintenance, and archival of documents, adhering to the Oaklawn Hospital document lifecycle process.
• Controls the retrieval of documents within the document system.
• Assists employees with document management procedures and policies, which include documentation, retention, retrieval, destruction and disaster recovery.
• Assists Lean facilitation and other quality improvement initiatives as requested.
• Assists with file migrations and audits, and performs administrative tasks as needed.

Minimum Qualifications:  Bachelor’s Degree or willing to complete a Bachelors degree program upon acceptance of the position.  Three (3) years’ experience supporting wide range of regulatory/accreditation activities (DNV/CMS/TJC) across the continuum of care.

Preferred Qualifications:  RN with active MI licensure.  Previous leadership experience. Certified Professional in Healthcare Quality (CPHQ) or Healthcare Accreditation Certified Professional (HACP) or Certified Joint Commission (CJCP) or equivalent. 

Knowledge Skills Abilities:  Consistently uses an outward mindset and puts forth exemplary effort in accomplishing his/her goals and objectives in a manner that helps others to achieve their goals and objectives.  Good communication skills, verbal and written. Self-directed and the ability to work independently. The candidate should be detail-oriented, dependable and trustworthy since they meet complex and sensitive documents. Organization skills required. Multitasking and prioritization skills required. Knowledge of Microsoft Word, Excel, etc. preferred. Ability to correlate various work documents and educate regarding documents required.

Working Conditions:  Work is generally performed within an office environment, with standard office equipment available, and visits to hospital areas is sometimes required which could have some exposure risk.

Physical Requirements:   Constantly see/visual acuity, handle/grasp/feel, talk/hear.  Frequently stand, sit, walk.  Occasionally lift 1 to 50+ lbs.