Accreditation Manager- Quality Assurance

Overview

Central Maine Healthcare (CMH), a member of Prime Healthcare Foundation, is an integrated healthcare delivery system serving approximately 400,000 residents across central, western, and midcoast Maine through a network of more than 40 primary and specialty care locations. The system includes Central Maine Medical Center  (CMMC) in Lewiston, a 250-bed, not-for-profit regional referral hospital that is home to the region's only Cancer Care Center, an orthopedic ambulatory surgery center, and the Central Maine Heart and Vascular Institute. CMMC also serves as the central Maine base for LifeFlight of Maine, the state's only medical helicopter service.

CMH also includes Bridgton Hospital and Rumford Hospital, two 25-bed critical access hospitals that provide essential care to Maine's rural communities.

As part of its commitment to healthcare education and workforce development, CMH is home to the Maine College of Health Professions, Maine's first nursing and medical imaging school. The private, not-for-profit institution is accredited by the New England Commission of Higher Education and plays an important role in training the next generation of healthcare professionals.

To learn more, visit www.cmhc.org.

Responsibilities

Develops and maintains the Central Maine Healthcare (CMH) system-wide continuous readiness program to sustain regulatory compliance for the Joint Commission (TJC) standards, Centers of Medicare and Medicaid (CMS) Conditions of Participation and Maine Department of Health and Human Services (DHHS) regulations. Oversees compliance with all payor recognition, public reporting requirements, care facilitation activity and system-wide quality assessment performance improvement initiatives for CMH. Responsible for assisting the organization with implementation of processes related to accreditation and patient safety to ensure alignment with organizational goals and regulatory requirements. Responsible for regularly assessing compliance and regulatory readiness and working with all sites of service to provide guidance and identify resources to resolve any deficiencies. Serves as an expert resource on regulatory/accreditation and licensure standards and expectations for compliance. Guides the development of policy and guidelines as they relate to compliance with regulatory and accreditation guidelines and assist in the interpretation of these policies. Responsible for providing frequent written updates to hospital and practice leadership on the department or practices’ compliance with applicable standards. Manages all Joint Commission accreditation visits, all CMS complaint investigation visits and all CMS triannual accreditation visits including on site and after visit activities.

Qualifications

EDUCATION, EXPERIENCE, TRAINING

1.    Bachelor’s Degree in Nursing, Healthcare Administration, Business, Engineering, or related field required.

2.    Master’s degree preferred.

3.    Current clinical license, if applicable.

4.    Minimum 5 years of related experience with Quality Management, Risk Management/Patient Safety and Performance Improvement program or related healthcare experience.

5.    Healthcare Accreditation Certification Program (HACP) or Certified Joint Commission Professional (CJCP) certifications will be required within 2 years of hire.

Employment Status

Shift

Equal Employment Opportunity

Company is an equal employment opportunity employer. Company prohibits discrimination against any applicant or employee based on race, color, sex, sexual orientation, gender identity, religion, national origin, age (subject to applicable law), disability, military status, genetic information or any other basis protected by applicable federal, state, or local laws. The Company also prohibits harassment of applicants or employees based on any of these protected categories. Know Your Rights: https://www.eeoc.gov/sites/default/files/2022-10/EEOC_KnowYourRights_screen_reader_10_20.pdf