Director Accreditation, Regulatory & Licensure - FT - Days - Quality

FTE

Scheduled Bi-Weekly Hours

Work Shift

Job Description

The Director Accreditation, Regulatory & Licensure (AR&L) provides leadership to ensure high quality, safe care by ensuring organizational systems and processes comply with the Joint Commission accreditation standards, CMS Conditions of Participation (CoPs), California Title 22 regulations and CDPH regulations.  Understands and assists all departments in achieving Licensure of programs and buildings with requirements in the State of California and in accordance with CDPH processes.  Leads, facilitates and supports activities relating to licensing, accrediting, and regulatory compliance.  Responsible for overseeing the external regulatory reporting required to outside agencies (Ex. CDPH). Collaborates with senior leadership, service-line directors, department leaders, clinical and medical staff to improve survey readiness. Provides oversight, education and guidance to meet regulatory standards and assure continued survey readiness.  Improves operational efficiency of regulatory and addresses identified opportunities to improve clinical quality across the enterprise.  Provides guidance, direction and expertise to assess and improve quality of care provided across the enterprise.  Provides oversight and input to the policy and procedure review process assuring that procedures are up to date and reflect evidence-based best practices. This Director will play a key role in organizing clinical and medical staff teams to accomplish the organizational and quality goals. Provides oversight and guidance to staff addressing regulatory and public reporting requirements.  Director will work with coordinators, leaders and managers to maintain certifications and improve care under Joint Commission Disease-specific certification. 

Key Responsibilities

Serves as the primary contact for all regulatory agencies: Supervises the administrative liaison when regulatory agencies are on-site, with the Manager of Accreditation and Regulatory Reporting. Assists the Sr. Director with development of and compliance with CMS QAPI standards, works to implement the Performance Improvement and Patient Safety Plan, and supports the clinical care contract evaluation process. Consults with organizational leaders regarding regulations and means to maintain compliance.  Ensures that leaders and employees are knowledgeable of regulatory standards.  Educates staff on changes in legislation and requirements related to regulatory accreditation and licensing issues. Assures continuity and consistency in compliance with regulatory issues across the organization by evaluating the impact of specific issues. Collaborates with clinical and medical staff leaders to develop and implement corrective action to minimize negative impact and maximize learning. Leads the Manager of Accreditation and Regulatory Reporting to prepare for surveys and inspections for all regulatory agencies.  Maintains relationship with representatives of regulatory agencies.  Ensures the organization monitors against regulatory standards to create a culture of ongoing compliance and patient safety. Leads all survey activities, responses, and plans of correction, and/or correspondence between the organization and TJC, CMS, & CDPH. Oversee insurance grievances (ex. Medicare QIO) responses in conjunction with HIM, Compliance, Patient Experience, Medical Staff, and Risk Management. Provides education and direction to enterprise managers and directors in addressing quality improvement across all service lines

Qualifications

• Degree in Nursing or Clinical healthcare related field preferred.
• Masters’ degree in Nursing or healthcare-related field, preferred
• 5 years of operations management experience preferred
• A minimum of 5 years management experience and 3 years recent experience in Joint Commission Survey preparation and Continuous Survey Readiness activities .
• Extensive knowledge of accreditation standards applicable to Hospital, Long Term Care, and Behavioral Health. Recent experience with CMS, State and Joint Commission surveys.
• Experience in leading change, designing and improving workflow/work processes. 
• Experience and credentials in Process Improvement Techniques (PDCA, Lean Six Sigma)
• Experience in staff education and effective communication and presentation skills.
• Demonstrated abilities in areas of project management, analytical interpretation and critical thinking.

License/Certification/Registration Requirements

• Current license as a Registered Nurse in the State of California, preferred
• Certified Professional in Healthcare Quality (CPHQ), preferred

Salary Range:

Sedentary Work - Duties performed mostly while sitting; walking and standing at times. Occasionally lift or carry up to 10 lbs. Uses hands and fingers. - (Physical Requirements-United States of America)