Accreditation and Compliance Specialist

The primary responsibility of the Accreditation and Compliance Specialist is the maintenance of Western Washington University (WWU) Student Health Center’s (SHC) certification with the Accreditation Association for Ambulatory Health Care (AAAHC).

This position works under general supervision and performs process/data analysis, assists in the development of policies, program evaluation, and performs compliance audits. This position provides consultative services to SHC Governing Body and staff regarding health care policy. We actively seek candidates from diverse backgrounds including communities of color, the LGBTQ community, veterans, and people with disabilities. The greater the diversity of our people, the better we can serve our community.

This is a full-time, 10-month cyclic, project position ending June 30, 2027. Modality will require in-person work in Bellingham on a regular basis. 

JOB DUTIES

% of time Duties / Responsibilities 

55% Maintenance of Accreditation:

• Develop and update policies for Student Health Center in alignment with University and AAAHC standards.
• Manage AAAHC policy and procedure review process. This includes setting document review schedules and tracking staff participation in these reviews.
• Maintain all AAAHC documentation stored in PowerDMS in coordination with supervisor and document owners.
• Serve as the expert on AAAHC requirements and perform regular review of AAAHC publications for changes in standards/requirements.
• In collaboration with the Student Health Center Governing Body provide SHC with ongoing readiness assessments for accreditation surveys across the AAAHC standards.
• Support AAAHC work groups and committees. This includes tracking deadlines for all accreditation activities, and assures all responses are on target to meet deadline or are escalated through necessary reporting structure to meet necessary compliance timeframe.
• Oversee the reaccreditation process lifecycle, including survey team visits, important submission dates, timely payments of all fees, documentation and reporting.

35% Regulatory Compliance and Data Privacy and Security:

• Support compliance with applicable data privacy and security laws and regulations in the Student Health Center in collaboration and with oversight from the WWU HIPAA Privacy Officer and HIPAA Security Officer.
• Develop and submit required annual reports.  

5% Training and Education for Staff:

• Communicate updates for privacy and security compliance and AAAHC guidelines to staff as needed.
• Assess training needs for SHC staff in regards to accreditation and compliance standards.
• Provide training opportunities for SHC staff to review and increase understanding.
• Engage with campus partners for additional training and advisement on AAAHC and patient privacy and security compliance standards.
• Foster a professional work environment that is collaborative, caring, and supports student and staff well-being. 

5% Other Administrative Duties:

• Oversee all Governing Body agendas and provide detailed minutes during meetings.
• Participate in and potential leadership of committee work.
• Participate in professional development regarding access, diversity, equity, and inclusion that advances abilities to best perform job responsibilities.
• Identify and mitigate project risks, updating leadership regularly.
• Other duties as assigned.  

Required Qualifications

• Bachelor’s degree or equivalent combination of education and experience producing comparable knowledge and abilities.
• Experience through one full lifecycle of accreditation surveys, with AAAHC or other equivalent.
• Knowledge of current national standards for medical clinic operations and current information privacy laws (including HIPAA and FERPA).
• Experience writing and updating policies and procedures, in alignment with national, state, and university regulations.
• Strong time management and organizational skills
• Strong demonstration of written and oral communication skills.
• Ability to prioritize and multi-task with minimal supervision in a dynamic work environment.
• Ability to role model growth mindset and developmental practices towards policy and procedure changes.
• Ability to identify and collaborate to remove inequities, barriers to access, and forms of oppression that may be present in the programming or services related to this position.
• Demonstrated awareness, knowledge, and skills to interact effectively with persons representing a wide range of diverse backgrounds.
• Familiarity with MS Office Suite of applications including Outlook, Word, Teams, Sharepoint and Excel.
• Experience working collaboratively with multi-disciplinary teams.
• Experience translating complex and technical subject matters into plain language writing for non-technical audiences.
• Experience developing policies that are accessible and support diverse teams. Examples may include practices of Universal Design etc.

Preferred Qualifications

• Leadership experience in project management.
• Experience working within the healthcare environment, preferably within college health, urgent care, or family practice.
• Experience in the AAAHC accreditation process.
• A Bachelor’s degree with major study in health care administration, or closely allied field.
• Familiarity with electronic medical records systems (such as PointnClick) and document management software (such as Power DMS).
• Ability to become a software ‘super user’ for PDMS and/or PointnClick.
• Experience with collecting and organizing organizational documents and reporting of data
• A strong commitment to creating a culturally responsive environment for staff and students, the delivery of programs that support diversity objectives, and the development of cultural engagement and responsiveness skills.

Special Requirements / Conditions of Employment

• Maintain continuing education relevant to assigned duties and for maintenance of any certifications or licensure.
• Pre-employment Criminal Background Check (required for new hires).
• WWU SHC follows CDC guidelines for Employee Health in a healthcare setting, including proof of several vaccinations and annual vaccinations during employment. Employees must show proof of compliance/willingness to comply by start date.

All employees must comply with our Immunization policies, including Proof of Rubeola Measles Immunity within 60-days of hire. Please reach out to  if you need information regarding medical or religious exemption and applicable accommodations.

Salary Hiring range is $58,070 - $66,780 depending on qualifications and experience.  Through longevity position tops out at $75,490/year.

Salary/Compensation: $58,070 - $66,780 per year

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