Accreditation Specialist

Albany Medical Center is hiring an Accreditation Specialist to support accreditation and CMS compliance, patient safety, and continuous improvement. The role conducts chart reviews and audits, supports survey preparation and corrective actions, and assists with data analysis, reporting, and departmental administration.

Responsibilities

• Independently gathers and summarizes information for reporting and other purposes
• Pursues continued education of standards, regulations, and requirements as put forth by the DNV, CMS, New York State, DOH, OSHA, and other regulatory bodies
• Educates self and has the ability to use the audit system proficiently
• Works with departmental leadership and other applicable stakeholders to resolve questions and issues
• Independently gathers and summarizes information for reporting and other purposes
• Meets all accreditation and CMS regulations for chart review
• Ability to use data analytics and databases to enter raw data, organize data, run reports, and help make interpretation of the data
• Uses proper protocols to access, view, and distribute personal health information necessary to do the job
• Performs chart audits on current inpatients and can perform tracers in patient care areas
• Coordinates and supports logistics during survey preparation, survey activity, and deficiency corrective action
• Copies, faxes and scans as needed to communicate for the department
• Establishes, maintains, and revises record keeping systems
• Meets all accreditation/CMS regulations for chart review protocols and assist department to do the same
• Greets, identifies and directs internal/external staff/inquiries in person or by telephone, and follows up as needed. Provides information and identifies solutions to address issues that arise and refers to appropriate person/authority as needed
• Available to all personnel who ask questions/make requests in a timely manner
• Assists users to obtain access to and training for the audit system
• Works with various programmatic groups to develop and implement strategies to improve Leapfrog measures
• Leads Accreditation presentations and other Accreditation Department led meetings, as necessary
• Proactively identifies and examines opportunities for improvement within the organization
• Leads departmental Environment of Care Rounds through appropriate patient care areas including hospital and clinical settings
• Escalates barriers identified if unable to help mitigate via chain of command within the department in a timely manner
• Assists with the oversight of the department intranet website content
• Additional duties as assigned

Company

• Academic medical center providing hospital care, education, and research.
• Albany, New York, USA
• http://www.amc.edu/
• Founded in 1839
• 5001-10000 employees

Qualifications

• requires a demonstrated high degree of knowledge, competence, and administrative support skills, and the ability to operate with considerable independence
• Glassdoor
• 3.3
• Academic medical center providing hospital care, education, and research.
• Albany, New York, USA
• http://www.amc.edu/
• Late Stage
• Leadership Team
• Jason Mouzakes
• President and Chief Executive Officer
• Recent News
• Bizjournals.com Feed (2025-11-12 15:43:17)
• New CEO for Albany Medical Center Hospital
• 2026-03-05
• Business Journals
• Hotel near Albany Medical Center sold
• 2024-05-28
• All four Albany Med hospitals to get updated branding
• 2022-09-19
• Company data provided by
• AI Tools
• Customize Your Resume
• Maximize your interview chances
• Build Cover Letter
• Make your application stand out
• Analyze How Well You Fit
• Understand your strength & weakness

Required skills

• CMS Regulatory Compliance, Chart Review, Data Analytics, Healthcare Accreditation, Healthcare Auditing

Experience

• Mid level