SUMMARY:
Serves as a consultant and an educator to Medical Center providers, colleagues, management, and senior leaders related to standards interpretation, evaluation of compliance, development of performance measurement systems, and design and implementation of improvement programs. Designs, implements, coordinates, and evaluates the Joint Commission/CMS Conditions of Participation continuous readiness program for the Joint Commission (TJC) Hospital Accreditation Program (HAP), the Critical Access Hospital (CAH) accreditation and the Joint Commission Lab Accreditation Program. Provides facilitation for teams working on regulatory compliance and/or accreditation processes. Manage day-to-day supervision of hospital based Regulatory Accreditation Coordinators.
REQUIREMENTS:
Bachelor's Degree is required – (Business Administration, Health Care Administration, Nursing, or healthcare related field preferred).
Ten (10) years of acute hospital or medical group regulatory/accreditation compliance experience required.
Minimum two (2) year of experience in a leadership role with or without direct reports required.
Experience with laboratory accreditation and/or disease specific certifications preferred.
Certification in applicable/approved field (healthcare related field preferred) required i.e.: Certified Healthcare Safety Professional (CHSP), Lean/Six Sigma, Emergency Management, CMS Hospital Restraint, Leadership, et al.
WHAT YOU WILL DO:
Monitor and manage direct reports timecards and PTO requests through UKG
Onboard and mentor new Regulatory Accreditation Coordinators, or maintain oversight of mentorship assignments within the team
Participates in hiring and employee relations for staff with assistance from the Regulatory Manager OR may participate & recommend in the hiring & selection process.
Shares and / or perform administrative tasks with and on behalf of the SAHS Regulatory Manager
Implement departmental plans & priorities identified by accountable leaders.
Develops and implements the activities of the organization-wide Joint Commission/CMS Conditions of Participation continuous readiness plan and continuously monitors the organization's state of readiness.
Coordinates Joint Commission, CMS, FDA, and other Regulatory/Accreditation onsite surveys and official correspondence and/or responses.
Maintains records of all accreditation and certification programs.
Facilitates interdepartmental and/or SAHS wide multidisciplinary teams to improve patient safety and regulatory compliance.
Develops and implements a regulatory compliance education/communication plan. Provides formal education and individual consultation on standards interpretation, implementation and monitoring.
Functions as a liaison to the health system regarding regulatory and accreditation functions.
Collaborate with Legal Advocacy department in monitoring legislative bills impacting the organization
Develops, organizes and maintains databases related to regulatory compliance and/or issues.
Displays, analyzes, and communicates data regarding regulatory compliance and/or issues.
Exercises critical thinking skills in conjunction with ever changing, high priority issues and regulations/standards.
Communicates both verbally and in written format with providers, hospital leadership, the public, other agencies, and hospital colleagues regarding regulatory compliance and/or issues.
Regularly reports on the status of continuous readiness to managers, directors, and senior leaders.
Ability to read and interpret licensure, accreditation, and regulatory standards.
Working knowledge of performance improvement.
Competency in each of the following functional areas:
a) Interpretation of basic inferential statistics and statistical process charting.
b) Database management.
c) Performance improvement methodology.
d) Adult education—teaching individuals, groups using adult learning principles.
e) Group facilitation and leadership.
f) Knowledge of healthcare organizational processes.
g) Competent skills with MS Word, Excel, and PowerPoint.
Recognized leadership skills
Evaluates and documents staff performance and oversees employee records for sites of responsibility OR participates in & contributes to the performance management/review process.
Provides operational guidance & support to the regulatory team
Disseminates policy/procedure updates to team and appliable stakeholders.
Supervises colleagues to ensure excellent professional customer service.
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.