PURPOSE STATEMENT:

The Director of Accreditation Readiness is responsible for ensuring proactive regulatory readiness of Acadia facilities with state and federal laws, regulations, and accreditation standards. As such, this role will be responsible for providing expert guidance and advice on all aspects of clinical documentation integrity, policy development and operational adherence, clinical protocols and programming fidelity, clinical aspects of the revenue cycle, EMR development and optimization, and regulatory compliance in Acadia facilities.

ESSENTIAL FUNCTIONS:

1. Strategic leader of best-in-class regulatory preparedness tactics
• Collaborates with facility leadership in establishment of operational performance consistency and adherence to regulatory and accreditation standards, as well as Acadia’s own internal expectations for delivery of quality care to patients.
• Supports a cohesive, enterprise-wide Process Improvement strategy, with real-time data visibility capabilities. Contribute to the development of a next-generation Process Improvement platform to support the development and sustainment of action plans for the resolution of problematic issues or to address areas of regulatory vulnerability and to broadly propagate a culture of quality, excellence, and continuous improvement across facilities.
2. Regulatory preparedness – support the implementation of sustainable survey preparation and process improvement initiatives to ultimately maximize achievement of zero- or standard-level survey outcomes.
• Serve as a primary and routine participant in the Survey Readiness Team (SRT) with responsibility for facility mock surveys, programmatic tracer activity, and the establishment of a broad culture of survey readiness.
• Mock surveys should occur 6-12 months prior to anticipated accreditation surveys and serve to prepare facilities for those point-in-time events and to improve ongoing process improvement initiatives and care delivery.
• Mock surveys should involve a robust post-SRT process with responsibilities, deliverables, and accountability at the facility level (ex. with the CEO, COO, clinical and quality leaders) and at the corporate level (ex. with the assigned Division Quality Director).
• Provide comprehensive, detailed reporting of results of mock survey and tracer activity to facility leadership and other key stakeholders such that there is clear visibility into areas of deficiency which require attention.
• • Actively monitor the post-SRT workstreams to ensure accountability and completion of assigned tasks by various stakeholders at the facility- and corporate-levels.
  • Support and teach facility leadership and corporate Quality colleagues to sustainably implement best-practices in regulatory/accreditation compliance as evidenced by ongoing process improvement initiative data, survey outcomes, and overall Quality KPIs in all facilities.
  • Assist in the development of tactical process improvement practices in facilities and maintenance of same including analysis of data and prioritization of efforts.
  • Translate standards, requirements, and policies into terms or processes meaningful to the target program.
  1. Documentation excellence and integrity – work collaboratively with facility leadership, medical staff, IT, outside vendors, and corporate leaders to address safety, standardization, and optimization of the essential components of the clinical revenue cycle and the overall clinical record systems.
  • Medical record development – the Director is responsible for supporting the development and standardization of Acadia’s clinical documentation formats, templates, and clinical processes, thereby establishing best practices for all paper medical record and electronic medical record systems, as directed by the VP of Accreditation Readiness.
  • Collaborates with corporate Compliance team to establish, develop, and maintain a library of ICD, PCS, CPT/HCPCS trainings, in conjunction with external coding contractor as needed.
  • Incorporate feedback from internal and external coding and documentation audits, including the Chart-to-Charge program, and such activities as conducted by the corporate Compliance team, facility leadership, and external auditing resources, into the development of documentation standards, templates, and processes.
  • Further, in conjunction with the corporate Compliance team, develop and deliver education and training on appropriate documentation for facility staff.
  • Serve as a subject-matter expert for and provide education to internal stakeholders at the corporate level (ex. IT, Compliance) and facility level (ex. HIM, Finance, medical staff) on regulatory and clinical process standards which underpin Acadia’s documentation templating and procedural standards and how those standards satisfy regulatory requirements.
  • Minimize errors and reduce exposure to fraud and abuse charges through thoughtful EMR, documentation, and process education.
  1. Assist with communications with regulatory agencies as appropriate, in conjunction with other corporate leaders, particularly those on the Patient Safety and Experience team

STANDARD EXPECTATIONS:

• Complies with organizational policies, procedures, process improvement initiatives and maintains organizational and industry policies regarding confidentiality.
• Communicate clearly and effectively to person(s) receiving services and their family members, guests, and other members of the health care team.
• Develops constructive and cooperative working relationships with others and maintains them over time.
• Encourages and builds mutual trust, respect, and cooperation among team members.
• Maintains regular and predictable attendance.

EDUCATION/EXPERIENCE/SKILL REQUIREMENTS:

• • Bachelor’s Degree in healthcare or related field, Master’s degree preferred.

1. • • A minimum of five years’ experience in psychiatric healthcare operations at the administrative/leadership level. Previous Medicare/Medicaid Operations/healthcare industry experience preferred.
     • Knowledge of relevant Joint Commission, CMS, CARF, DEA, and state/local standards and regulations.
     • Experience in conducting complex compliance investigations, preferably in healthcare.
     • Advanced computer skills including Microsoft Office; especially Word, Excel, and PowerPoint.
     • Knowledge of office administration procedures with the ability to operate most standard office equipment.
     • Ability to work professionally with sensitive, proprietary data & information while maintaining confidentiality.
     • Excellent interpersonal skills including the ability to interact effectively and professionally with individuals at all levels; both internal and external.
     • Exercises sound judgment in responding to inquiries; understands when to route inquiries to next level.
     • Self-motivated with strong organizational skills and superior attention to detail.
     • Must be able to manage multiple tasks/projects simultaneously within inflexible time frames. Ability to adapt to frequent priority changes.
     • Capable of working within established policies, procedures and practices prescribed by the organization.
     • English sufficient to provide and receive instructions/directions.