GENERAL SUMMARY:

Provides interpretation of all Joint Commission standards with special emphasis on standards issues related to specific settings, professional disciplines, or accreditation programs. Combines systems analysis skills with in-depth general and program-specific knowledge to evaluate health care organizations’ compliance and ability to provide high quality, safe patient care. Participates as a consultant in the development and revision of standards and survey process. Participates in ongoing accreditation services and special projects. Serves as faculty for surveyor and other education programs and represents the Joint Commission as liaison to various professional organizations. In conjunction with operations team, ensures that accredited organizations receive excellent customer service and that their accreditation needs are met.

PRINCIPAL DUTIES AND RESPONSIBILITIES:

1. Provides guidance on and expert interpretation of Joint Commission standards and Medicare requirements, professional standards of practice, and law and regulation to internal and external customers including but not limited to: field representatives, service teams, Office of Quality and Patient Safety (OQPS), other divisions, Joint Commission Resources (JCR) field staff, accredited organizations, those seeking accreditation or certification, professional associations, governmental agencies, consultants, educators and students.
2. Leads and coordinates the intracycle monitoring process. Provides high-level analysis of organizational data including: performance measures, survey outcomes, and data submitted by organizations as part of the intracycle monitoring process in order to identify existing and/or potential vulnerabilities and risk points that could impact the organization’s ability to provide quality care in a safe environment. Provides coaching and mentoring to customers and shares information regarding the changing healthcare environment including newly identified issues and trends, leading practices to assist in the development of corrective actions and utilization of Joint Commission tools.
3. Supports the entire accreditation/certification process through the development, review and analysis of survey reports and outcomes, interactions with the field representatives and accredited customers, serving as a resource to the account executives and making recommendations on accreditation/certification decisions to the Accreditation Committee of the Board of Commissioners including the appeal process.  
4. Works closely with OQPS to provide support to the complaint analysis process through: the review of complaints as indicated providing information on potential standards non-compliance; the development of assessment maps to guide the surveyor(s) conducting OQPS surveys and participates in preparatory conference calls as needed.
5. Provides leadership and guidance to the Accreditation and Certification Operations (ACO) service teams in all aspects of the accreditation process through clinical expertise and customer relationship management.
6. Serves as a role model in the support of and implementation of enterprise, division and departmental mission and initiatives utilizing Robust Process Improvement (RPI) tools and strategies as indicated. Leads and/or participates in internal work groups to identify and implement improvements to our internal processes. 
7. Provides direction and guidance to internal and external customers in the consistency of standards interpretation through inquiry and frequently asked questions (FAQ) management processes, educational offerings, publications and media and social networking opportunities. Serves as faculty for field representative training (both TJC and JCR), Speaker’s Bureau and JCR seminars and workshops. Participates in strategic business unit (SBU) teams or other program specific committees and work groups, as assigned. 
8. Effectively communicates with internal and external customers in a respectful, constructive and collegial style. Consistently provides excellent customer service to all internal and external customers. 
9. Embraces The Joint Commission culture of safety and serves as a role model in incorporating the SIG Department Guidelines into daily work and interactions.
10. Serves as a resource for Media Relations in the development of responses to inquiries from external media representatives and /or requests for interviews.

KNOWLEDGE, SKILLS AND ABILITIES REQUIRED:

• Healthcare RN clinician with master’s degree (or actively working on it) with a minimum of five years of experience in outpatient and/or inpatient healthcare setting. 

• Demonstrated analytical, inductive and deductive reasoning skills.

• Demonstrated excellent customer relationship management skills.

• Demonstrated positive peer and leadership relationships

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

• Strong writing and speaking skills.

• Demonstrated ability to function well in a fast-paced, highly visible and challenging environment.

• Demonstrated ability to problem solve and manage multiple priorities meeting and/or exceeding customer expectations with regards to turn around time and quality of the response/interaction.

• Strong computer skills preferred including word processing, presentation software and databases.

WORKING CONDITIONS:

• Must be able to lift 25 pounds

• Must be able to climb stairs and ladders and work in settings with infectious diseases

• Must be able to travel up to 20% of work time.

This job description is intended to describe the general nature and level of work performed by an employee assigned to this position. The description is not an exhaustive list of all duties, responsibilities, knowledge, skills, and abilities, and working conditions associated with this position