Job Summary:

The Quality and Accreditation Coordinator provides direct administrative, operational, and programmatic support to the Director of Quality & Accreditation at Jackson County Memorial Hospital Authority (JCMHA). This position supports the Director of Quality & Accreditation with coordinating grant monitoring and reporting activities across federal, state, and private funding sources, supports accreditation readiness and survey activities, assists with regulatory reporting and quality improvement functions, and coordinates TEAM patient tracking and information distribution. The incumbent works under close supervision and serves as an organizational resource for compliance, accreditation, quality, and grant-related workflow execution.

Demonstrates Competency in the Following General Areas:

• Commits to 100% patient and customer satisfaction by always exhibiting a courteous and helpful manner during interactions with others, including patients, families, visitors, physicians, co-workers, and contractors.
• Maintains a general, overall working knowledge of the department's mission, thereby having the ability to provide basic service and support to others. Recognizes when others need assistance and consistently offers to help when own workload permits.
• Fully knowledgeable of Hospital policies and procedural flow, and able to apply this knowledge to all situations.

Demonstrates Competency in the Following Primary Duties:

• Accreditation Support:

– Assist with maintenance of required accreditation documents, ensuring materials are current, organized, and readily accessible for survey activities.

– Assist with coordination of on-site surveys including annual accreditation survey and other on-site survey activities.

– Assist with monitoring of accreditation survey corrective actions, tracking completion status and escalating outstanding items to the Director of Quality & Accreditation as appropriate.

– Assist with dissemination of survey readiness and accreditation information through scheduled channels, including monthly calls, weekly emails, and other designated communications.

– Participate in monthly rounds conducted for survey readiness purposes, documenting observations and supporting follow-up activities as directed.

• Regulatory Reporting:

– Assist with ensuring regulatory reporting requirements are met in compliance with applicable State, CMS, and other governing body requirements and deadlines.

– Assist with the review and distribution of reports received from CMS and other regulatory agencies, routing materials to appropriate staff and maintaining distribution records.

• Quality Improvement Support:

– Assist with ongoing audit initiation, completion, and closure activities, including coordinating audit schedules, gathering documentation, and tracking status through resolution.

– Assist with preparation of quality reports, compiling data and supporting materials for review by the Director of Quality & Accreditation and hospital leadership.

– Assist with meeting agendas, reminders, and minutes for quality-related committees and workgroups, ensuring timely distribution and accurate recordkeeping.

• Transforming Episode Accountability Model (TEAM) Support:

JCMHA participates in the Transforming Episode Accountability Model (TEAM) as a mandatory CMS episode payment model. TEAM participation carries direct financial and regulatory implications; accurate tracking, timely reporting, and proper documentation are essential to JCMHA’s performance and payment reconciliation under this model.

– Maintain accurate and current records of TEAM episode patients, including episode initiation, care coordination activity, participant follow-up, and episode closure in accordance with CMS TEAM model requirements and established internal workflows.

– Assist with monitoring of TEAM performance data and reconciliation reports, flagging discrepancies or missing documentation to the Director of Quality & Accreditation in a timely manner.

– Assist with review and distribution of TEAM program information, CMS communications, and performance data to appropriate staff and leadership, maintaining organized distribution records.

– Support preparation of TEAM-related reporting and documentation required for CMS submission deadlines, coordinating with clinical, finance, and quality staff to ensure completeness and accuracy.

– Maintain working knowledge of CMS TEAM model requirements, updates, and compliance obligations; escalate changes in program requirements or identified compliance concerns to the Director promptly.

• Grant Compliance Monitoring & Reporting:

– Serve as the primary point of coordination for grant compliance monitoring activities across federal (e.g., HRSA, HHS, USDA), state (e.g., OSDH, ODMHSAS), and private/foundation funding sources.

– Maintain grant compliance files, funder correspondence, award documents, reporting calendars, and conditions of award documentation.

– Track grant reporting deadlines and deliverable schedules; provide advance reminders to the Director and relevant department contacts.

– Compile and organize data, narratives, and supporting documentation required for periodic grant progress and financial reports.

– Coordinate with Finance, department leads, and program staff to gather reporting inputs; review submissions for completeness prior to Director review.

– Maintain a current grant inventory log documenting active awards, performance periods, reporting requirements, and compliance status.

– Assist with preparation of grant closeout documentation and records disposition at award conclusion

Professional Requirements:

• Wears identification while on duty; meets dress code standards; appearance is neat and clean.
• Reports to work on time and as scheduled, uses time and attendance system correctly and completes work within designated time.
• Attends mandatory meetings; attends and/or reads minutes of other scheduled meetings.
• Respects patient confidentiality and uses discretion of patient information.
• Participates in continuing educational activities as deemed appropriate by supervisor. Completes annual education requirements for infection control and safety.
• Strong attention to detail and deadlines.
• Effective written and verbal communication skills.
• Organizational and file management competency.
• Demonstrated ability to coordinate across multiple departments and functional areas simultaneously.
• Ethical conduct and professional discretion.

Educational/Experience/Regulatory Requirements:

• Bachelor's degree in healthcare administration, business administration, public health, or a related field required. An equivalent combination of education and directly related experience may be considered.
• Minimum two (2) years of administrative, coordinator, or program support experience required; experience in a healthcare or regulated industry setting strongly preferred.
• Prior experience supporting accreditation, quality improvement, grant administration, compliance programs, or policy management is highly desirable.
• Intermediate to advanced proficiency with Microsoft Office Suite (Word, Excel, Outlook) required; ability to learn and operate Meditech Expanse, RLDatix, or equivalent healthcare information systems.
• Familiarity with CMS and DNV/NIAHO accreditation standards and regulatory reporting requirements is a plus; willingness to develop competency in these areas is required.
• Understanding of the needs of rural healthcare and familiarity with the Jackson County area is a plus.

Language Skills:

• Must be able to read and communicate effectively in English.
• Must be able to communicate (orally and in writing) effectively with patients, physicians, and other departments in the institution.

Physical Demands:

• Work may be stressful. Must be able to meet, communicate, and work with patients and public directly, orally, and in writing.
• Vision: Near visual acuity required to perform essential duties such as reading documents, computer screens, and detailed reports.
• Hearing: Hearing acuity essential for effective communication with team members and stakeholders.
• Repetitive Motion: Frequent use of a computer keyboard and mouse for data entry, report writing, and communication.
• Environment: Primarily works in an office setting with standard office equipment. May require occasional movement within the hospital for meetings, rounds, audits, and project oversight. Prolonged periods of sitting while working on a computer or attending meetings.
• Stress Management: Ability to handle stress and work under pressure, especially when managing multiple concurrent deadlines across compliance, accreditation, and quality functions.
• Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the position without compromising patient care.