POSITION TITLE: Corporate Manager-Regulatory & Accreditation
POSITION LOCATION: Near Any Major Airport
Manager, Regulatory and Accreditation is responsible for assessing, developing, educating, implementing, monitoring, and leading the system wide Regulatory and Accreditation activities within the company’s hospitals. This includes preparation and survey readiness. The position develops and implements processes for current safe practices within the organization. The Manager Regulatory and Accreditation work closely with other corporate departments, regions, and facilities for collaboration and synergy around identified priorities. Assesses emergency management and refers disaster preparedness and business continuity to appropriate personnel. Develops, educates, implements, monitors, and leads regulatory requirements and accreditation standards, goals and targets through collaboration with corporate departments and the Regional Directors of Regulatory and Accreditation RDRA. Is a leader for the Quality Department in the formulation of organizational regulatory and accreditation related goals and targets. Assists with the development of the corporate strategy and tactics for regulatory and accreditation preparation and successful surveys based on the company Regulatory and Accreditation Plan. Tracks progression and sustainment of the company regulatory and accreditation strategy and tactics per standardized reporting process. Provides input for strategic development, planning and implementation of system Quality Department Regulatory and Accreditation Plan/activities.
Bachelor’s degree in nursing preferred, with experience in regulatory requirements and accreditation standards, performance improvement as applicable in other related areas of responsibility.
Requires an advanced degree in a health related field (Masters or Doctorate) within five years of relevant facility management experience.
Knowledge of TJC and other regulatory standards.
Knowledge of CMS CoP Conditions of Participation and other federal requirements.
Knowledge of CMS CoP Conditions of Participation and other state requirements.
Knowledge of principles of quality improvement.
Relevant clinical experience.
At least 10 years of experience leading a multi-hospital system Regulatory and Accreditation program.
Experience leading interdisciplinary initiatives in process improvement and directly with improving reliability of healthcare delivery at the point of care.
Certified Joint Commission Professional (CJCP) within six months of hire date.
Experienced with and practiced at performance improvement activities.
Skilled at developing and conducting educational presentations.
Expert at remediating findings when in a facility.
Adept at developing methods, tools, reports, data aggregation and conducting regulatory and operational surveys for facilities, including the review of regulatory requirements and accreditation standards and Conditions of Participation.
Prepares written reports of clinical and operational survey findings.
Skilled in developing corrective action plans, provide educational programs, monitor implementation of action plan and other oversight activities through follow-up visits to facilities as needed, and provide guidance on regulatory and accreditation communications as needed.
Expert on regulatory requirements and accreditation standards, preparation activities, and success with surveys.
Trained on outcomes and quality management and using and applying quality management diagnostic tools (defect analysis, fault tree analysis).
Knowledgeable in the areas of peer review, risk management, patient safety, infection control prevention and reporting.
Expert on TJC, Centers for Medicaid and Medicare, Quality Improvement Organization (QIO), state requirements and other regulatory standards / processes.