Manager of Accreditation and Regulation

Position Purpose

The Manager of Accreditation and Regulatory is a qualified individual who provides leadership, direction, and support for continual regulatory readiness. The function of the role manages accreditation, certification, and survey activities in conjunction with Director of Regulatory and Accreditation. Supports continuous readiness structure and key relationships with operational leadership improvements, and continuous improvement plans for safety culture and regulatory compliance.

Nature and Scope

• The manager assists in the design and implementation of the comprehensive programs with systemic approach to identifying, designing, measuring, and monitoring of all regulatory improvement activities.

• The manager’s scope of work includes education and training on accreditation and regulatory guidelines for all team members within the organization, including executives; operational leadership of teams and large groups across the health system; management of comprehensive programs, analysis and monitoring of all accreditation and regulatory improvement activities; continuous management of performance data; and compliance with regulatory standards guidelines

• The position requires leadership skills and knowledge to leverage shared experience in accreditation and regulatory survey processes and builds upon current knowledge of requirements related to CMS Conditions of Participation and The Joint Commission.

• Develops and delivers education regarding internally and externally driven trends in healthcare licensure, accreditation, and regulatory compliance.

• Facilitates accreditation/regulatory efforts involving operational leadership and departments to assess policies, evaluate workflows, observe clinical care, interview team embers, assess environment of care, etc. with goal of identifying gaps, consulting on priority of items needing correction, researching, and advising on reliable compliance strategies utilizing evidence-based practice.

• Assists Director of Accreditation and Regulatory Compliance in facilitating a system wide approach to assessing and meeting regulatory requirements and process improvements.

• Consistently aligns priorities of accreditation and regulatory compliance efforts with hospital's culture of safety and supports efforts to ensure compliance.

• Participates in and supports in evaluation of incidents and complaints, as needed.

• Supports operational leadership of laboratory department to track status of laboratory licenses/CLIA certificates, identify compliance opportunities, and to implement of corrective actions.

• Assists Director of Regulatory and Accreditation with coordination of all regulatory surveys by the Joint Commission, CMS, etc., and support department-specific surveys by regulatory and accreditation authorities such as FDA, DEA, CAP, etc., as needed.

This position works in tandem with the Hospital Accreditation Program, Total Joint Certification, Comprehensive Obstructive Pulmonary Disease Certification, Advanced Comprehensive Stoke Center Certification, Safety Management Program, Trauma Designation, Home Health Hospice Accreditation Program, and State of Nevada Endorsements.

This position does not provide patient care.

Disclaimer

The foregoing description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills and efforts or work conditions associated with the job. It is intended to be an accurate reflection of the general nature and level of the job.

Minimum Qualifications

Requirements - Required and/or Preferred