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Registered Nurse Accreditation/Performance Improvement Specialist Full Time in Sebring, FL at AdventHealth

Date Posted: 6/16/2019

Job Snapshot

  • Job Schedule
  • Location:
    Sebring, FL
  • Job Category
  • Date Posted:
  • Job ID:
  • Job Family
    Quality/Clinical Effectiveness
  • Travel
    Yes, 25 % of the Time
  • Shift
    1 - Day
  • Application Zone
    1-Shared Services
  • Organization
    AdventHealth Sebring Wauchula Lake Placid

Job Description


" Registered Nurse Accreditation/Performance Improvement Specialist Full Time" AdventHealth Sebring

Location Address: 4200 Sun 'n Lake Boulevard Sebring, FL 33872

Top Reasons to Work at AdventHealth Sebring

  • Faith Based & Mission driven Facility

  • Largest Employer in the County

  • Surrounded by beautiful Lakes, Golf Courses and Florida’s oldest State Park

  • Close knit community with a home town family feel

  • 2 hours to just about any beach on either Coast

Work Hours/Shift:

Full Time- Days

You Will Be Responsible For:

  • Provides direction to department and facility leadership in planning of a systematic, organization- wide approach to continuous regulatory readiness

  • Chairs the Continuous Survey Readiness Committee

  • Communicates relevant changes to standards

  • Prepares reports and/or presentations

  • Coordinates educational materials/ presentations for committee members

  • Coordinates the planning and execution of the TJC intra-cycle monitoring (ICM)

  • Conducts tracer activity within the hospital and the clinic setting

  • Performs chart abstractions, audits, and documentation reviews to identify compliance with regulatory bodies.

  • Interviews staff through the tracer methodology process

  • Prepares summaries of gathered information

  • Participates in EOC rounds

  • Plans, develops, and conducts educational programs on accreditation for employees

  • Facilitates mock surveys and assists in the development of plans for improvement

  • Prepares survey specific documentation as requested by regulatory agencies

  • Participates in on-site surveys, including coordination of agendas, coordination of scribes, communication with surveyors and on-site staff, and communication of preliminary findings

  • Facilitates the development of corrective action plans as part of post-survey activities

  • Collaborate with all members of the healthcare team

  • Maintains knowledge in regulatory compliance

  • Conducts Failure Mode Effect Analysis (FMEA) as indicated/ required by regulatory entities and in accordance with the Patient Safety Plan

  • Attends and provides support for multiple hospital committees, such as UR/Performance Improvement/Patient Safety, Glycemic Management, Water Management, Environment of Care, Emergency Management, etc.

  • Self-directed in maintaining and improving own competence in cognitive aspects of nursing practice


What You Will Need:
  • Associates Degree in Nursing
  • Minimum 3 years as acute care nurse
  • Registered Nurse with current licensure to practice in the State of Florida required
  • Strong organization skills, including completing work by established deadlines.

  • Ability to evaluate and correlate clinical information with appropriate criteria and is able to utilize available computer hardware and software.

  • Skills to develop and engage in educational activities to facilitate learners’ achievement of specific objectives.

Job Summary:

The Accreditation/ Performance Improvement Specialist serves as a member of the Quality Department. This position leads regulatory survey readiness program planning for AdventHealth Lake Placid, Sebring, and AdventHealth Wauchula. This position coordinates survey activities, i.e. The Joint Commission (TJC), Agency for Health Care Administration (AHCA), and CMS Validation Surveys. This position is also responsible for managing selected Performance Improvement Initiatives within the facility. This individual proceeds on their own initiative in compliance with policies and procedures prescribed by the Quality Department leadership.


This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances.

Location | Organization | Category | Job Function