Accreditation and Regulatory Program Leader

Employment Type:

Shift:

Description:

Required Qualifications:

• Education:
• Bachelor's degree in nursing, pharmacy or other clinical or health care systems background. Master's degree in healthcare or healthcare-related field and Six Signma training at green belt or higher is preferred.
• Advanced interpersonal skills necessary to effectively communicate complex theoretical and technical concepts effectively with a wide variety of individuals.
• Advanced analytical and computer skills in order to manage project work and data.
• Advanced critical thinking skills necessary to develop sound recommendations and assist in implementing improved delivery of care systems, policies and procedures, evaluating clinical practice outcomes and developing educational programs.
• Manages and directs the implementation of organization regulatory compliance activities across all areas, partnering with unit and program managers and leaders as appropriate.
• Leads the organization in pre-survey activities.
• Coordinates organizational response during CMS, state licensing surveys and Joint Commission surveys.
• Communicates survey results, develops action plans and survey responses in accordance with regulatory timelines.
• Manages complaint responses and associated action plans.
• Manages the routine and ongoing function of the accreditation software, Joint Communication extranet, and monitors the CMS.gov websites to assure compliance with regulatory reporting requirements.
• Utilizes performance improvement methodologies and change management strategies to address identified compliance gaps in regulations and standards.
• Strategizes with various levels of leadership to develop organization response to new regulations and standards with health system leadership.

Experience:

• A minimum of five years clinical experience, including at least one to two years in leadership or management. Experience with and understanding of key functions of hospital and medical staff departments or services. Previous accreditation experience with an in-depth understanding of regulatory requirements and healthcare operations is preferred. Certificate as a Joint Commission Professional (CJCP) preferred.
• Physical and Mental Requirements and Working Conditions:

What you will do:

• Manages and directs the implementation of organization regulatory compliance activities across all areas, partnering with unit and program managers and leaders as appropriate.
• Leads the organization in pre-survey activities.
• Coordinates organizational response during CMS, state licensing surveys and Joint Commission surveys.
• Communicates survey results, develops action plans and survey responses in accordance with regulatory timelines.
• Manages complaint responses and associated action plans.
• Manages the routine and ongoing function of the accreditation software, Joint Communication extranet, and monitors the CMS.gov websites to assure compliance with regulatory reporting requirements.
• Utilizes performance improvement methodologies and change management strategies to address identified compliance gaps in regulations and standards.
• Strategizes with various levels of leadership to develop organization response to new regulations and standards with health system leadership.
• Our Commitment
• Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.

Preferred Qualifications

• Bachelor's degree in nursing, pharmacy or other clinical or health care systems background. Master's degree in healthcare or healthcare-related field and Six Signma training at green belt or higher is preferred.
• A minimum of five years clinical experience, including at least one to two years in leadership or management. Experience with and understanding of key functions of hospital and medical staff departments or services. Previous accreditation experience with an in-depth understanding of regulatory requirements and healthcare operations is preferred. Certificate as a Joint Commission Professional (CJCP) preferred.