Clinical Accreditation Specialist

  • Oakland, CA
  • Quality
  • Risk Management
  • Full Time - Day
  • Req #: 25157-16489
  • Posted: November 25, 2019
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It's fun to work in a company where people truly BELIEVE in what they're doing!  We're committed to bringing passion and customer focus to the business.  If you like wild growth and working with happy, enthusiastic over-achievers, you'll enjoy your career with us!


Alameda Health System has a workforce dedicated to excellence. Our current staff help make AHS the best place in Alameda County to learn and to work.  AHS’s leadership deeply appreciates the individuals contributions of all who serve our patients and their families, directly or behind the scenes. One of our mottos is “Serving All” and that is evident by our employees who are also a part of the culturally diverse communities we serve.  


AHS is dedicated to helping members of the AHS family excel in their jobs, fulfill career milestones, and embrace the AHS pledge of top performance. We are investing in more training and equipment that support our caregivers’ ability to do what they do best, from recently implementing EPIC to better serve our patients, and support our staff to investing in top of the line medical equipment in various clinical departments across our hospitals and wellness centers.


If you join us, we desire you to be compassionate, informed, and engaged because we know those employees deliver quality care and improved outcomes for our patients.  Please visit our jobs page to see if there is a place for YOU at Alameda Health System!


Plans, coordinates, monitors and improves compliance to and maintenance of Federal, State and Accreditation regulations; manages accreditation activities necessary for attaining and maintaining accreditation and licensure from various organizations, such as (JC) Joint Commission, California Department of Public Health (CDPH), CMS (Center Medicare Services), CDPH (CA Dept of Public Health) Lab Field Services, CDPH Radiologic Health Branch, etc.; prioritizes projects, coordinates action plans, and monitors/analyzes results for accreditation projects, consistent with the organization's strategic goals and imperatives.


1. Facilitates and coordinates liaison activities with accreditation and regulatory agencies (i.e. California Department of Health, The Joint Commission, Centers for Medicare & Medicaid Services etc. including tracking, evaluation and submission of required documentation, survey preparation, arranging on-site visits, required responses, and completion of action items.
2. Assists in all accreditation and regulatory activities, including surveys, survey preparation and readiness assessments.
3. Actively coordinates the organization’s readiness rounds program and is primarily responsible for the development, communication, implementation and tracking of action plans necessary to close identified gaps in care or compliance with The Joint Commission (TJC) standards and Centers for Medicare and Medicaid Services (CMS) and Title 22 regulations.
4. Responsible for reporting unusual occurrence and adverse events to the appropriate regulatory body.  
5. Responsible for tracking, reporting, and ensuring the completion of action items resulting from survey findings.
6. Leads and conducts survey preparatory project meetings and project tracking, analysis and identification of deficiencies necessary to correct in order to achieve compliance with standards.
7. Provides education to the organization on regulatory and accreditation issues.
8. Provides oversight of Facility Self Assessment and Intracycle Monitoring activities.
9. Develops comprehensive accreditation work plans by establishing deliverables, accountabilities, and timelines.
10. Tracks and trends compliance issues.
11. Performs other duties as required.


NOTE: The following are the duties performed by employees in this classification.  However, employees may perform other related duties at an equivalent level.  Not all duties listed are necessarily performed by each individual in the classification.


Required Education: Bachelor's Degree with a healthcare related focus.
Required Experience: Five years (5+) health-care related experience.

Required Licenses/Certifications: Valid license to practice as a Registered Nurse in the State of California.

and/or: NP (Nurse Practicioner), PA (Physician Assistant), LVN (Licensed Vocational Nurse)

Preferred Education: Master’s Degree with a healthcare related focus
Preferred Experience: Familiar with Midas, Epic / Electronic Health Record (EHR), County Health Systems, OSHPD. 
Preferred Licenses/Certifications:
CPHQ (Certifed Professional Healthcare Quality) and/or CJCP (Certified Joint Commission Professional) and/or Certified in Healthcare Compliance (CHC) and/or Certified Professional in Patient Safety (CPPS), and Project Management Professional (PMP) other applicable certifications.

Please visit our website to find benefits and salary information. 


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