Director of Accreditation

Position Summary:  Person in this position will be responsible for coordinating and monitoring assigned aspects of the national accreditation process to ensure that WestCare policies and procedures, national accreditation standards, state licensing regulations and other applicable federal, state, and local rules and regulations are met. Essential job functions include those listed below: 

Essential Job Functions: 

Submit assigned accreditation applications.  

Collaborate with assigned regions to develop state specific policies upon request. 

Assist assigned regions with CARF survey preparation assignments. 

Collaborate with Incident Reporting workgroup and participate in any scheduled meetings/assignments.  

Participate in assigned National Operations sub-committee.  

Ensure Annual Review of Policy forms are signed by leadership, uploaded to the intranet, and distributed during the accreditation call.  

Coordinate with Vice President to develop policies, procedures, plans and processes across WestCare to ensure regions meet accreditation standards. 

Provide training and assistance to staff that is designed to improve understanding of the accreditation process and requirements, conformance to accreditation standards and adherence to regulatory requirements. 

Update CARF manual changes document annually and provide education regarding revisions to accreditation standards during scheduled accreditation calls. 

Conduct regular conference calls with regional management staff to facilitate sharing of strategies and techniques among regions to obtain and maintain conformance to accreditation standards.  

Perform site-based reviews to determine level of conformance with accreditation standards,  

prior to on-site surveys occurring.  

Assist with the development and implementation of all plans required to conform to accreditation standards, coordinate annual development or review of plans and upload documents to the accreditation tab on the intranet. 

Embrace and embody the mission, vision, guiding principles, clinical vision, and goals of WestCare Foundation.  

Other relevant duties as assigned. 

Education:  

Master’s degree in healthcare or related field preferred; Bachelor’s degree in healthcare or related field plus comparable years of qualifying experience. 

Essential Qualifications: 

Current CARF surveyor or willingness to become one.  

Management/leadership experience.  

Detail oriented. 

Ability to develop positive relationships with all levels of personnel.   

Experience in public-funded health and human services organization. 

Knowledge of accreditation standards, grants, contract and regulatory compliance. 

Excellent written and oral communication skills and interpersonal skills. 

Superior organizational skills and attention to detail. 

Working Conditions: 

Office and/or remote setting.  

Local and out-of-State travel, including overnight stays. 

Great deal of computer work. 

The normal work routine involves no exposure to human blood, body fluids or tissues. Persons who perform these duties are not called upon as part of their employment to perform or assist in emergency medical care or first aid to be potentially exposed in some other way 

Essential Physical and Mental Demands of the Job: 

The employee must be able to perform the following essential duties and activities with or without accommodation: 

Physical Demands: 

Requires mobility and physical activity: Having an adequate range of body motion and mobility to work in an office, residential, or outdoor environment including standing and walking (even and uneven surfaces), sitting for extended periods of time, bending, twisting, reaching, balancing, occasional lifting and carrying of up to 30 pounds. Use of computer and telephone systems is required which includes coordination of eye and hand, and fine manipulation by the hands (typing, writing, and working with files). Requires the ability to defend oneself and clients in physically abusive situations through the use of approved physical de-escalation techniques. 

Requires talking: Expressing or exchanging ideas by means of the spoken word. Talking is required to impart oral information to employees, clients, patients, and the public, and in those activities in which the employee is required to convey detailed or important spoken instructions to others accurately, loudly, or quickly. 

Requires hearing: Hearing is required to receive and communicate detailed information through oral communication. 

Requires seeing: Clarity of vision at 20 inches or less and at distance. This factor is required to complete paperwork for many of the employee's essential job functions and to observe client behavior and activities in and out of the facility. 

The normal work routine involves no exposure to human blood, body fluids or tissues. However, exposure or potential exposure may be required as a condition of employment. Appropriate personal protective equipment will be readily available to every employee. 

Mental Demands: 

Requires the ability to collect and analyze complex numerical and written data and verbal information to reach logical conclusions. 

Requires the ability to work and cooperate with clients, co-workers, managers, the public and employees at all levels in order to exchange ideas, information, instructions and opinions. 

Requires the ability to work under stress and in emotionally charged settings. 

The ability to defend oneself and clients in mentally/verbally abusive situations through the use of approved mental/verbal de-escalation techniques.