Job Description 

Job Summary

Develops, implements, evaluates strategy, programs, policies and practices to ensure organization wide compliance with federal, national, state and other licensing and accreditation standards. Directs the preparation of organizational readiness, survey readiness activities and regulatory inspections as requested by Administration. Serves as resource on matters related to accreditation and regulatory to maintain organization in continual survey readiness state. Develops and manages departmental budgets and administers human resources in area of responsibility.

Minimum Job Requirements

• Bachelor Degree in a Health Care related field.
• 7-10 years of Accreditation leadership experience for a hospital or healthcare system.

Job Specific Duties

• Develops, assists, implements, evaluates strategy, programs, policies, and practices to ensure organization wide compliance with federal, national, state and accreditation standards. Ensures compliance with accreditation and regulatory agencies by analyzing standards, rules, regulations, and policies in order to maintain organization in continual state of accreditation and survey readiness. Implement, direct and monitor a formal accreditation/regulatory readiness plan.
•  Maintain and communicate regulatory/accreditation requirements and standards to applicable staff, physicians, and leadership. Leads regulatory readiness oversight committee and develops appropriate reporting, tracking methodologies to assess and monitor status.
•  Works with clinical and facilities leaders to develop safety policies and procedures for review and approval by the Environment of Care Committee. Assists in defining performance indicators for evaluation of the Safety Program. Performs rounding across the system to ensure safety readiness.
•  Manages and monitors the organizations' accreditation and regulatory (i.e. DNV, ISO, AHCA, CMS, etc.) communication, as well as essential deadlines to ensure optimal timelines of compliance (i.e. complaints or deficiencies to accreditation organization).
•  Serves as a regulatory and safety expert and resource for leadership and staff. Prepares reports for presentation to organization groups and committees to maintain accreditation/regulatory readiness. Provides reports as requested to state and/or federal regulatory entities.
•  Develops, coordinates, and manages annual departmental capital and operating budget achieving department fiscal objectives and prepares written variance and other reports as requested.
•  Selects, develops, and manages staff to achieve the desired state of competency required to maintain a state of continual survey readiness for the organization.
•  Manages staff productivity and other performance markers including annual evaluation. Ensures corrective action as required according to organization policy. Provide on-going training for new and existing employees on various department duties, procedures, and systems.
•  Develops departmental strategies and plans, as well as improvement of work management processes and provides input on organizational objectives as required. Completes all necessary records and reports in a timely and accurate fashion.
•  Continuously evaluates operations and implements process improvements that reduce or eliminate waste, increase efficiency, quality, safety, satisfaction, and cost-effectiveness. Promote and practice cost containment.

Knowledge, Skills, and Abilities

•  Master’s degree preferred.
•  Accreditation certification or equivalent preferred.
•  Access and Visio experience preferred.
•  Excellent verbal, written, and presentation skill.
•  Highly effective with interpersonal communication.
•  Excellent program development and planning skills to ensure regulatory and accreditation compliance is incorporated across the organization.
•  Ability to design and direct appropriate education and training activities.
•  Ability to interpret, analyze and summarize data, and regulatory requirements.
•  Ability to effectively direct organization staff, leadership, physicians, and regulatory/licensing bodies.
•  Proficient in Microsoft Office Suite (Word, Outlook, SharePoint, Excel, and PowerPoint).
•  Continuously improving of professional growth and expertise through participation in relevant training and education.
•  Reacts effectively to unplanned circumstances, demands and challenges facing the organization, and in particular assigned area of responsibility.
•  Collaborates effectively throughout the organization to ensure goals and objectives are achieved.