Job Title: Joint Commission Tracer Location: New York, New York Local, Remote or Hybrid: Local Schedule: Full Time; 5X8 M-F 9AM-5PM. Each Tracer will be assigned a specific campus location. Must be able to work at any of the 8 main campuses. Contractors may be asked to float between facility locations depending on the need. Contract: 17 weeks, through 12/31/26 Important Call Outs: NYP Vaya Coversheet Required Qualifications Education: - Bachelor's Degree (R) - Master's degree (P) Experience: Minimum 5 years of experience, primarily in healthcare-related roles (R) Quality Assurance experience is crucial MUST have hospital healthcare experience Knowledge of Joint Commission, CMS and DOH requirements and/or experience with Joint Commission or regulatory survey activity (R) 3+ years Project Management experience; ability to plan and lead project, facilitate project scope, develop project plans, manage timelines and provide direction and support to project team (P) Experience with desktop computer applications and knowledge of database concepts. Advanced skills with Microsoft applications including Outlook, Word, Excel, PowerPoint, and other web based applications (R) Excellent communication skills, both oral and written (R) Experience with managing and interpreting data (R) Ability to manage multiple activities and meet timelines and deadlines (R) Ability to work with a variety of departments and levels of personnel Key Responsibilities: Participates in hospital-wide continuous readiness activities to facilitate ongoing hospital compliance with Joint Commission, CMS and DOH requirements. Serves as subject matter expert for hospital teams assessing compliance with Joint Commission and other regulatory standards and requirements. Collaborates with departments, service lines, operations and clinical units on the implementation of standardized processes for accreditation and regulatory activities across the NYP Enterprise. Assists hospital teams in assessment of compliance with Joint Commission and other regulatory standards and requirements. Facilitates development and monitors completion of corrective action plans and any related data measurement and analysis Lead multiple aspects of the hospital -wide continuous readiness activities to facilitate ongoing hospital compliance with Joint Commission, CMS and DOH requirements. Ongoing readiness activities include tracing activity, internal mock survey, ongoing focused standards assessment, training and education and facilitation with outside consultants. Independently assess and respond to requests from surveyors. Guides operational leaders in how to respond to requests and reviews documentation from operational leaders to ensure documentation meets requests of the survey team. Exercises judgement to determine what must be escalated. Synthesizes complex information for operational and senior leaders. Identifies areas of risk. Reviews and interprets hospital or departmental data and monitoring tools to ensure that standards are measured appropriately. Works with management to measure, interpret, and analyze data to ensure compliance, progress, and tracking towards corrective action plans. Maintains current knowledge of external standards and regulations, including but not limited to, the Joint Commission, CMS, and the DOH. Utilizing this knowledge, serves as subject matter expert and assesses whether hospital and departmental policies, practices, and processes are in compliance with new and existing regulatory standards. Collaborates with departments, service lines, and clinical units to implement standardized processes for accreditation and regulatory activities. Interprets standards and identifies acceptable evidence of compliance in order to meet Joint Commission, CMS and DOH requirements. Serves as a liaison between hospital leadership and surveyors. Coordinates with command centers, answers surveyor questions, obtains information from various departments. Designs and delivers educational trainings to enhance the organizational knowledge of accreditation and regulatory requirements. Identifies and presents areas of regulatory risk to the organization including senior management. Reports results from mock surveys to department leadership. Participates in hospital regulatory programs in various roles, including but not limited to: survey escort, survey runner, and various tracing activity. Manages FSA teams including identifying areas of risk and collaborating with teams on corrective action plan. Maintains central repository of all hospital survey activity on an ongoing basis and provides key reports to leadership regarding regulatory activity. Participates in various hospital and Quality committees, work groups, or task forces as assigned, including enterprise-wide quality goals Project manage one or more quality goals annually. May be assigned to perform daily checks of hospital secure Joint Commission extranet site, for timely notification of all clinical alerts, process changes, or survey activity. Performs other job related duties as assigned.
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