PCMH Accreditation Manager

The PCMH Accreditation Manager is responsible for coordinating and overseeing accreditation, regulatory compliance, and survey readiness activities within Rural Health Clinics (RHCs). This position ensures compliance with applicable federal and state regulations, Centers for Medicare & Medicaid Services (CMS) Conditions of Participation, and accreditation standards established by the hospital’s accrediting organization, such as The Joint Commission or DNV, as applicable.

The Accreditation Manager collaborates with hospital and clinic leadership, clinical departments, medical staff, and supports services to maintain continuous survey readiness, monitor compliance, identify opportunities for improvement, and support a culture of patient safety and quality care. This position utilizes the hospital’s electronic medical record (EMR) and other information systems to conduct documentation audits, monitor compliance indicators, identify trends, and support corrective action plans.

The Accreditation Manager serves as a resource for regulatory interpretation, policy and procedure management, audit coordination, and ongoing compliance education to ensure the hospital maintains readiness for accreditation surveys, CMS surveys, and other regulatory reviews.

JOB DESCRIPTION:

· Accreditation and Regulatory Compliance

· Coordinate and oversee PCMH accreditation activities and ongoing survey readiness.

· Maintain current knowledge of regulatory changes and communicate applicable requirements to hospital leadership and department managers.

· Coordinate preparation for accreditation surveys and other external reviews.

· Conduct routine compliance rounds, tracers, and departmental assessments to identify gaps in regulatory compliance.

· Maintain survey documentation, evidence of compliance, and supporting records.

· Assist departments in interpreting and implementing applicable regulatory and accreditation requirements.

· EMR Documentation and Compliance Auditing

· Utilize the hospital’s EMR to conduct audits of clinical documentation, patient records, orders, assessments, care plans, and discharge documentation.

· Evaluate medical record documentation for compliance with regulatory requirements, hospital policies, and applicable accreditation standards.

· Collaborate with nursing, providers, health information management, pharmacy, and other departments to address documentation deficiencies.

· Identify trends in documentation errors, incomplete records, and workflow issues that may affect regulatory compliance or patient safety.

· Partner with EMR analysts and information technology staff to improve documentation workflows, templates, reports, and compliance monitoring tools.

· Support implementation and monitoring of EMR changes related to regulatory requirements, documentation standards, and quality initiatives.

· Educate staff on documentation expectations, required elements, and appropriate use of the EMR.

· Protect confidentiality, integrity, and security of patient information in accordance with HIPAA and organizational policies.

· Quality Improvement and Patient Safety

· Collaborate with the Quality Department and hospital leadership to support performance improvement and patient safety initiatives.

· Monitor quality indicators, audit results, and compliance trends to identify opportunities for improvement.

· Assist with root cause analyses, corrective action plans, and follow-up monitoring when deficiencies or noncompliance are identified.

· Participate in quality assurance and performance improvement (QAPI) activities.

· Track corrective actions to ensure timely completion and sustained compliance.

· Support a culture of safety, accountability, continuous improvement, and regulatory awareness.

· Policy and Procedure Management

· Coordinate the review, revision, approval, and maintenance of hospital policies and procedures to ensure alignment with current regulations and accreditation standards.

· Maintain a centralized policy management process and monitor review dates and approval status.

· Work with department leaders and subject matter experts to ensure policies reflect current practices and EMR workflows.

· Identify discrepancies between written policies, regulatory requirements, and actual operational practices.

· Assist departments with implementing revised policies and communicating changes to affected staff.

· 5. Education and Staff Development

· Develop and provide education regarding accreditation standards, regulatory requirements, survey readiness, and documentation compliance.

· Coordinate training and communication following regulatory changes, survey findings, and internal audit results.

· Provide guidance to department managers and staff regarding compliance expectations and corrective actions.

· Support new employee orientation and ongoing competency or education activities related to regulatory compliance, as assigned.

· Survey Findings and Corrective Action

· Coordinate responses to accreditation and regulatory findings in collaboration with hospital leadership and affected departments.

· Assist in developing plans of correction and evidence of compliance as required.

· Monitor corrective action deadlines and evaluate the effectiveness of implemented interventions.

· Maintain documentation of corrective actions, follow-up audits, and sustained compliance.

· Report significant compliance risks, unresolved deficiencies, and survey readiness concerns to hospital leadership.

· Communication and Collaboration

· Serve as a liaison among hospital leadership, clinical departments, medical staff, regulatory agencies, and accrediting organizations regarding accreditation and compliance matters.

· Facilitate interdisciplinary meetings focused on regulatory compliance, survey preparation, and performance improvement.

· Prepare reports, dashboards, and summaries of audit findings, compliance risks, and improvement activities.

· Promote accountability and collaboration across departments to maintain a continuous state of survey readiness.

· Other Duties

· Maintain confidentiality of patient, employee, and organizational information.

· Participate in committees, meetings, and special projects as assigned.

· Perform other duties consistent with the role and organizational needs.

· Performs additional duties as assigned.