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Job Details

Deputy Director, Accreditation and Certification

Requisition #: 185411
Location: Johns Hopkins Hospital/Johns Hopkins Health System, Baltimore, MD 21201
Category: Leadership
Work Shift: Day Shift
Work Week: Full Time (40 hours)
Weekend Work Required: No
Date Posted: April 27, 2019

Johns Hopkins Health System employs more than 20,000 people annually. When joining the Johns Hopkins Health System, you became part of a diverse organization dedicated to its patients, their families, and the community we serve, as well as to our employees. Career opportunities are available in academic and community hospital settings, home care services, physician practices, international affiliate locations and in the health insurance industry. Great careers continually advance here.

Position Summary:

The Deputy Director, Office of Accreditation & Certification, is responsible for supporting the enterprise-wide regulatory and operations in partnership with the Senior Director, Office of Accreditation & Certification and under the purview of the Vice President, Risk Management.

This position’s responsibilities include leading and/or facilitating inter-professional system-wide workgroup meetings; managing projects that support enterprise-wide standardization and/or harmonization; managing databases, and designing and conducting data analyses that optimize clinical documentation and workflows to maximize regulatory compliance across the health system. The Deputy Director will collaborate with and lead the Clinical Auditors in monitoring continuous readiness at all health system entities.

Responsibilities:

•<span style="font: 7pt/normal "Times New Roman"; font-size-adjust: none; font-stretch: normal;"> Collaborate with Senior Director to coordinate programs or projects that help fulfill the mission of the health system.

•<span style="font: 7pt/normal "Times New Roman"; font-size-adjust: none; font-stretch: normal;"> Chair/co-chair health system workgroups to harmonize/standardize strategies to assure regulatory compliance.

•<span style="font: 7pt/normal "Times New Roman"; font-size-adjust: none; font-stretch: normal;"> Actively participate in departmental and/or system-wide committees, sharing expertise and representing regulatory point of view.

•<span style="font: 7pt/normal "Times New Roman"; font-size-adjust: none; font-stretch: normal;"> Manage Clinical Auditors work as resource/consultant to internal and external customers – planning and facilitating all mock surveys.

•<span style="font: 7pt/normal "Times New Roman"; font-size-adjust: none; font-stretch: normal;"> Pre-survey work:

<span style="font-family: "Courier New";">o<span style="font: 7pt/normal "Times New Roman"; font-size-adjust: none; font-stretch: normal;"> Develop and implement an inventory of regulatory auditing strategies.

<span style="font-family: "Courier New";">o<span style="font: 7pt/normal "Times New Roman"; font-size-adjust: none; font-stretch: normal;"> Maximize use of regulatory data platforms (currently limited to Converge and Soleran at JHH and AMP at HCGH).

•<span style="font: 7pt/normal "Times New Roman"; font-size-adjust: none; font-stretch: normal;"> Post-survey work:

<span style="font-family: "Courier New";">o<span style="font: 7pt/normal "Times New Roman"; font-size-adjust: none; font-stretch: normal;"> Resource for citation workgroups.

<span style="font-family: "Courier New";">o<span style="font: 7pt/normal "Times New Roman"; font-size-adjust: none; font-stretch: normal;"> Help set appropriate monitoring strategies that will be needed as part of the response plan.

<span style="font-family: "Courier New";">o<span style="font: 7pt/normal "Times New Roman"; font-size-adjust: none; font-stretch: normal;"> Review/revise all corrective action plans from 6 hospitals before submission to external regulators.

Knowledge:

Understanding of policies, procedures, regulations, standards, organizational structure, and information systems used in academic and community settings. Knowledge of health care business operations, design and management of EPIC, and project management processes. Knowledge of Federal and state regulatory guidelines and requirements and accrediting organizations’ standards – TJC, CMS and MIEMSS, etc.

Education:

Master’s degree required. Master’s Degree in Nursing or Allied Health is preferred.

Work Experience:

Minimum 5 years of related healthcare experience in operational, administrative, or management required, preferably within an academic medical center.

Shift:

Days, Full Time (40 hours)

8:30 am – 5:00 pm

Exempt, Pay Grade: AD

Work Location:

JHH, 600 North Wolfe Street

Skills:

  • <span style="font: 7pt/normal "Times New Roman"; font-size-adjust: none; font-stretch: normal;"> Interpersonal skills. Able to work with and effectively communicate with all levels of staff in a health care organization.
  • <span style="font: 7pt/normal "Times New Roman"; font-size-adjust: none; font-stretch: normal;"> Organizational skills. Able to navigate complex organizations; understand both the clinical and the operational side of health care operations in academic and community settings; manage projects, timetables, deliverables, and evaluations.
  • <span style="font: 7pt/normal "Times New Roman"; font-size-adjust: none; font-stretch: normal;"> Data management and analytic skills. Apply quantitative analysis skills to database management and operational decision making. Proficient in use of software applications (e.g., spread sheets, word processing, presentation programs).
  • <span style="font: 7pt/normal "Times New Roman"; font-size-adjust: none; font-stretch: normal;"> Writing skills. Excellent writing skills and be able to develop concise memorandums, reports, proposals.

Required Licensure, Certification:

None

Working Conditions:

Works in normal office environment where there are limited physical discomforts due to temperature, noise, dust, etc. Work requires attention to detail and requires mental/visual acuity. Work requires periodic travel to other entities.

Johns Hopkins is a Smoke – Free campus.

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Johns Hopkins Health System and its affiliates are drug-free workplace employers.

Johns Hopkins Health System and its affiliates are an Equal Opportunity / Affirmative Action employers. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity and expression, age, national origin, mental or physical disability, genetic information, veteran status, or any other status protected by federal, state, or local law.

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