Job Summary

The Accreditation Specialist serves as lead in coordination and facilitation of accreditation and regulatory work for all Oregon licensed behavioral health facilities at BestCare Treatment Services (BCTS) ensuring that the organization is in substantial conformance to the applicable CARF standards, and in compliance to licensing regulations. Prompt and effective communication with supervisor and other leadership on compliance issues and concerns and supporting the development of site leadership and staff to uphold the standards in the day-to-day operations of BCTS business functions, programs and services is essential. Serves the organization to promote ongoing operational alignment with the current Oregon Administrative Rules (OAR) and CARF standards to educate, update, interpret, and operationalize current, existing, and new changes to the policies, procedures and plans for facilities, site leadership, administrative departments, and executive leadership.

Essential Functions

1. Establishes collaborative relationships with the management team and line staff focused on helping the teams to improve knowledge base and understanding in CARF standards conformance and OAR compliance.

2. Serves as content expert for the organization regarding interpretation and implementation of CARF standards and OARs, state licensing site reviews and CARF surveys.

3. Directs on-site accreditation survey support. Facilitates review and training of program staff, documentation and processes with facility management and leaders. Reviews survey materials at least quarterly and provides education at least annually to ensure strong coordination and staff knowledge of role during external surveys.

4. Educates and communicates effectively to support sites and staff to successfully pass CARF surveys and State site reviews at each BestCare location and program.

5. Partners with various departments to support implementation of CARF Standards; draft and execute policy & procedures; as well as develop and implement core competencies and workflows to support the regulatory responsibilities set forth.

6. Advises internal performance improvement and quality assurance efforts with CARF scope and understanding to strengthen and/or define the initiatives and responsibilities. This includes but is not limited to:

· Quality Record Review

· Performance measurement, management and analysis

· Compliance and Risk Management

· Health & Safety

· Clinical Programs and Services

7. Process Improvement:

a. Identifies and evaluates risk factors relative to BCTS’s compliance and program integrity obligations; identifies potential areas of compliance vulnerability and ensures corrective action to reduce or mitigate these risks.

b. Develops, implements, and oversees program integrity functions, including prevention and detection of fraud, waste, and abuse; responds promptly to potential instances of fraud or abuse, reporting to appropriate state and federal agencies.

c. Proactively addresses accreditation and regulatory compliance issues; works with other departments/system staff to assign ownership and works to correct identified issues prior to external regulatory review.

d. Report as required and appropriate

8. Leads the Residential Programs and Outpatient programs to achieve and maintain CARF accreditation and state certification:

a. Supports policies and procedures’ draft and implementation to meet CARF standards and OAR regulations

b. Assists with the development and implementation of internal audits, regulatory training and education for leaders and staff related to program integrity and compliance.

c. Effectively collaborates with the Privacy and Security Officer(s) and chief compliance officer on compliance-related issues.

d. Creates tools for managers to utilize to maintain conformance and compliance in their designated units.

e. Facilitates local regulatory expertise to promote operational compliance using standard tools and approaches, consistent interpretation of rules and regulations, standardization of process/practice, and outcomes management

9. Drives outcome through data and collaboration

a. Supports the development and maintenance of key performance measures according to CARF Standards and Oregon Health Authority (OHA).

b. Ensures the tracking, analysis, and regular reporting of outcome data to key data consumers.

10. Participates in CARF Surveying with 3 or more surveys per year upon approval with the direct supervisor.

Qualifications:

Education, Certifications and Licensure

· A Bachelor’s Degree in behavioral health/social service/public health or nursing plus 5 years of related experience required

Master’s Degree plus 2 years of related experience preferred.

Related experience includes provision of clinical services, and administrative standards for risk management, health and safety, quality assurance, performance improvement. Familiarity with corporate compliance and Oregon state rules preferred.

· Current State licensure in related field

· Valid Oregon Driver’s License and eligibility to be insured by company policy

· SUD certification preferred

Experience

· Experience in a CARF accredited organization required.

· Current CARF Surveyor preferred. Current or previous experience as CARF staff considered.

· 3 years’ experience in behavioral health services setting.

· 3 years’ experience in using an EHR, understanding clinical documentation practices, chart navigation, and data analytics

Knowledge, Skills, and Abilities

· Possesses strong analytic skills, ability to interpret data; facility with using Excel.

· Ability to demonstrate sound critical thinking/decision-making and ability to work with others to facilitate problem resolution for system improvement.

· Excellent verbal, written and presentation communication skills; highly developed organizational, interpersonal, and management skills.

· High-level proficiency in Microsoft Office- MS Word, Excel, Access, and PowerPoint.

· Knowledge of evidence-based practices and accepted standards for clinical documentation

· Ability to maintain confidentiality of highly sensitive information

· Ability to prioritize and manage multiple projects

· Ability to work effectively in multiple cultural contexts

· Fluent in Spanish / bi-lingual with English preferred

· Ability to develop strong collaborative relationships with a range of team members and community partners

Physical Demands:

The physical demands described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

This position is performed indoors 95% of the time and requires a mixture of sedentary and light working conditions. While performing this job, the employee is continuously required to utilize hands, wrists, and arms, and have manual dexterity to feel or operate objects or controls. The employee is frequently required to sit, stand, walk, talk, and hear. May occasionally be required to climb or balance; stoop, kneel, crouch, or crawl, lift and/or carry up to twenty (20) pounds, or push pull a cart with weights > twenty (20) pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.

Work Environment:

The work environment is multi-cultural and inclusive, and the characteristics described above are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

The position requires the employee to dress in a professional manner that meets the standards for professional attire in Central Oregon.

Job Type: Full-time

Pay: $22.31 - $29.27 per hour

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Employee assistance program
• Health insurance
• Life insurance
• Paid time off
• Professional development assistance
• Relocation assistance
• Vision insurance

Schedule:

• 8 hour shift
• Day shift
• Monday to Friday

Ability to commute/relocate:

• Redmond, OR 97756: Reliably commute or planning to relocate before starting work (Required)

Experience:

• Customer service: 1 year (Preferred)

Work Location: One location

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