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Quality and Accreditation Manager, Montpelier, ID

Organization: Bear Lake Memorial Hospital
Category: Marketing & Sales
Location: Montpelier, ID
Date Job Posted: March 5, 2020
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Quality and Accreditation Manager

Regular Part Time (32 hours)
Montpelier, ID
Posted 3 days ago

Bear Lake Memorial Hospital

Count On Us To Care

Reports To: Director of Nursing Services
Experience: 1 -2 years’ experience preferred
Desired Education Level: Registered Nurse License with preferred Bachelors’ Degree in Nursing

Bear Lake Memorial Hospital is seeking an intelligent, highly organized and hard-working Quality and Accreditation Manger.

Responsibilities include, but are not limited to:

Accreditation Manager Duties:

  • Lead the accreditation plan for each accrediting body and review/submission cycle.
  • Oversee ongoing accreditation maintenance processes, including reports, self-studies, site visits, and reviews.
  • Develop and maintain positive rapport with accreditation agencies and other applicable federal/state/local regulators.
  • Disseminate education and awareness of federal/state/local mandates for compliance.
  • Oversee the preparation, submission and performance tracking for achieving and maintaining regulatory standards and standards for accreditation.
  • Collaborate with Department Heads with compliance standards.
  • Enforce work deadlines as they apply to accreditation requirements.
  • Gather, review and maintain a complete and updated licensing/accreditation inventory record for each program and oversee the reconciliation of any approval issue and/or problem.
  • Ensure official documents are submitted to the appropriate governing body and retained in appropriate filing system.
  • Comply with federal, state, and local legal requirements by studying existing and new legislation; enforcing adherence to requirements; advising management on needed actions.
  • Comply and advise Administration on design and implementation of program evaluations and development of program improvement strategies.
  • Communicate results of all surveys to administration.
  • Perform other tasks as directed by administration.
  • Plans of correction will be written by the Department involved or in conjunction with Quality Assurance and reported to the Committee.

Quality Assurance Manager Duties:

  • Assist in the planning, organization and direction of Quality Assurance and Performance Improvement programs and related activities.
  • Assist Department Heads and staff in the evaluation of programs and effect changes as necessary to improve programs and assure compliance with regulatory requirements.
  • Assist in the coordination of studies performed within the Quality Assurance and Performance Improvement program and prepare reports as required.
  • Establish and maintain tracking systems for identified problems/indicators.
  • Develop and implement appropriate plans of action to correct identified deficiencies as needed.
  • Perform administrative requirements such as completing forms, writing reports, etc., and submit to the Director of Nursing, Administrator or appropriate agency as directed.
  • Participate in meetings as directed.
  • Schedule committee meetings and notify members of such meetings.
  • Assist Departments in developing indicators and follow-up procedures for identified problems.
  • Assist in developing a reference library of written quality assessment and assurance material, laws, etc., necessary for complying with current standards and regulations, and that will provide assistance in maintaining quality resident care.
  • Make written and oral reports/recommendations to the Director of Nursing, as necessary/required, concerning the operation of the Quality Assessment and Assurance program.
  • Assist in developing annual auditing schedules for all Departments as well as audit development when identified.
  • Assist in the maintenance of tracking logs, incident and accidents, medication errors etc. and monitor for trends requiring corrective actions.
  • Assist in the investigation of incidents, injuries, sentinel events, abuse and misappropriation of resident property. Summarize findings and file reports to appropriate staff and agencies.
  • Assist in the development and delivery of educational programs revolving around all components of Quality Assurance, including orientation for new employees and programs to address the Quality Assurance process and Regulatory guidelines.
  • Participate and assist in departmental studies and projects as assigned.
  • Attend and participate in workshops, seminars, etc., to keep abreast of current changes in the health care field, as well as quality related topics.
  • Assist in reeducation of staff when developing corrective action plans from completed audits or chart reviews. Ensure documentation of remediation and report to Department Head.
  • Maintain the confidentiality of all resident care information.
  • Knowledge of resident rights and responsibilities, including the right of refusal.
  • Ensure resident rights to fair and equitable treatment, self- determination, individuality, privacy, property and civil rights, including the right to wage a complaint, are well established and maintained at all times.
  • Serve on Quality and Safety Oversight Committee.
  • Attend Quality and Safety Oversight Committee monthly meetings.


  • Registered Nurse License in the state of Idaho.
  • Ability to sit and work at computer station for several hours of a work day.
  • Must be highly organized.
  • Strong written and oral communications skills
  • Exceptional organizational and prioritization skills
  • Proven ability to maintain confidentiality
  • Strong ability to work well with others
  • Ability to work autonomously and as a team member in a fast-paced, deadline-driven environment
  • Excellent communication skills
  • Computer proficiency (MS Office) essential.
  • Strong ability to teach and interact various personality types.

To apply:

Please submit your application to the HR Dept., Bear Lake Memorial Hospital, 164 South 5th Street, Montpelier, ID, 83254 or you may fax it to (208) 847-4334. Applications are available at

Expiration: Applications will be accepted until filled.

Bear Lake Memorial Hospital is an equal opportunity employer and all applicants will be given fair consideration based on their academic credentials and applicable work experience.

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