The Joint Commission

Clinical Accreditation Analyst

Job Locations US-IL-Oak Brook
Job ID
2020-4124
# of Openings
1

Overview

Responsible for reviewing, analyzing and writing outcome evaluations for client accreditation/certification survey reports and post-survey follow-up reports based on correct application of the decision rules, e.g. survey findings reports, strategic improvement plans (SIP), self-assessments of standards compliance, and intra-cycle reviews. Responsible for editing, proofreading and formatting the accreditation survey reports, accreditation, and other client documents. Maintains selected databases and provides statistics, trends and reports. Prepares memos and other documents for the JCI Accreditation Committee.  Provides program specific knowledge and information to internal and external customers and fellow staff.

Responsibilities

PRINCIPAL DUTIES AND RESPONSIBILITIES

  1. Validates international accreditation survey reports to assure appropriate scoring, interpretation of standards, suggest appropriate follow-up activities and edits reports for clarity and consistency from the clinical perspective.

 

  1. Provides clinical analysis of strategic improvement plans submitted by international health care organizations to assess reported compliance progress and develop written response to the progress reports.

 

  1. Under the guidance of the Associate Director(s) or Director, analyzes the documents, data, and materials submitted by the organization in support of a disputed finding(s), expedited denial of accreditation, appeal of an accreditation decision or other circumstance.

 

  1. Conducts video or telephone conferences or video survey activities with client organization and JCI accreditation program staff and surveyor(s) to evaluate compliance with standards, implementation of the strategic improvement plan (SIP), intra-cycle compliance monitoring of performance measures and quality improvement data.

 

  1. Collaborates with the JCIA staff to facilitate timely post-survey process activities; meets the specified report turn-around time targets; and provides accurate data for preparing the monthly metric statistics. Works with administrative staff in preparing final reports to be sent to clients. 

 

  1. Assists in resolving on-site clinical issues as requested by the team leader in conjunction with the Associate Director(s) or Director, as needed.

 

  1. Acquires a thorough understanding of all JCI accreditation/certification program standards, decision rules, scoring guidelines and accreditation policies and procedures; keeps abreast of changes that affect report content and production.

 

  1. Supports the development and revision of the standards, survey process, scoring guidelines, and aggregation and decision rules for all accreditation programs.

 

  1. Represents the JCI in a professional manner to customers, staff within the enterprise, as well as professional organizations and the general public.  

 

  1. Participates in JCIA team activities, meetings, and process improvement activities, as appropriate. Participates in JCR committees, task forces, and special projects as assigned.

 

  1. Promotes cooperation, flexibility, and teamwork; demonstrates an effective interpersonal communication style among staff and other team members to assure the work environment is positive and productive.

 

Qualifications

KNOWLEDGE, EXPERIENCE, AND SPECIAL SKILLS REQUIRED:

 

  1. A health care professional with a minimum of a bachelor’s degree; Master’s Degree preferred in a clinical or administrative healthcare management preferred; current Illinois license required.  RN greatly desired

 

  1. At least five years of clinical experience in an accredited hospital or healthcare organization.

 

  1. Knowledge of Joint Commission or Joint Commission International policies, standards, survey, and accreditation processes.

 

  1. Knowledge of patient safety and quality principles and practices.

 

  1. Excellent analytical skills, with the ability to communicate outcomes in an effective, clear, and efficient manner both verbally and in writing.

 

  1. Interpersonal skills to interact effectively with individuals at various levels both inside and outside of the organization, sometimes in sensitive situations.

 

  1. Organized, detailed-oriented, with good decision-making skills; capable of handling multiple priorities efficiently, and working both independently and in groups.

 

  1. Excellent computer skills in word processing, spreadsheets, database, and presentation software. Familiarity with web based and video communication capability preferred.

 

  1. International travel may be required up to 5%, including assisting with on-site surveys or making effective presentations to stakeholder groups.

 

  1. Foreign language skills are an asset for example languages such as spoken in Asia, Middle East, Europe or Latin America. .

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