Centerstone is among the nation’s leading nonprofit behavioral health systems with thousands of employees dedicated to delivering care that changes people’s lives. A dynamic, well-established organization, we offer rewarding opportunities to serve all ages in a variety of settings. Come talk to us about joining the Centerstone team!
JOB DESCRIPTION:
Position Summary
The Accreditation and Governance Specialist supports Centerstone's enterprise Accreditation & Quality Governance program by promoting continuous survey readiness, regulatory compliance, and consistent implementation of accreditation standards across all markets and service lines.
This position partners closely with operational leaders to interpret accreditation standards, conduct mock surveys and tracers, monitor corrective action plans, and prepare the organization for regulatory and accreditation surveys.
The Accreditation and Governance Specialist serves as a subject matter resource on accreditation requirements and collaborates with Clinical Excellence, Clinical Risk Management, Patient Voice & Experience, and Policy Governance to strengthen organizational quality and regulatory compliance.
Essential Duties and Responsibilities
Support enterprise accreditation readiness initiatives across all Centerstone markets and service lines.
Conduct mock surveys, tracers, and readiness assessments to evaluate compliance with accreditation standards and organizational policies.
Partner with operational leaders to identify opportunities for improvement and strengthen continuous survey readiness.
Assist with preparation for accreditation and regulatory surveys, including document review, evidence collection, and survey logistics.
Monitor compliance with accreditation standards and communicate identified risks or deficiencies to leadership.
Assist in developing and monitoring corrective action plans resulting from accreditation surveys, mock surveys, tracers, and regulatory reviews.
Collaborate with operational leaders to ensure timely completion of corrective actions and ongoing compliance activities.
Provide education and consultation regarding accreditation standards, regulatory expectations, and survey readiness.
Assist with interpretation of accreditation standards and communicate updates to operational leaders.
Participate in enterprise readiness committees and quality governance activities.
Collaborate with Policy Governance to ensure policies and procedures align with accreditation standards and regulatory requirements.
Collaborate with Clinical Excellence to incorporate findings from chart reviews, tracers, and clinical quality evaluations into survey readiness efforts.
Collaborate with Operations/Clinical management to identify trends that may impact accreditation readiness or regulatory compliance.
Completes activities associated to SAMSHA survey
Completes activities necessary to ensure certification of Centerstone locations in National Health Services Corps (NHSC) and the opportunity for enrollment of Centerstone staff into NHSC programs
Assists in activities to ensure compliance with Federal Rule 1557 of Affordable Care Act regarding non-discrimination activities.
Maintain documentation and records related to accreditation readiness activities.
Participate in enterprise quality improvement initiatives as assigned.
Represents the department on internal organizational committees and functions. Acts as a representative of Centerstone externally with key stakeholders relevant to work of the department.
Periodic travel may be required to support organizational priorities, including leadership collaboration, incident response activities, staff development, and other Clinical Risk Management initiatives. Travel expectations will vary based on organizational needs.
Perform other duties as assigned.
Supervisory Responsibilities
This position does not have supervisory responsibilities.
Knowledge, Skills and Abilities
Working knowledge of healthcare accreditation standards…