Job Description

Job Summary:

Leads the Accreditation and regulatory compliance program of the organization. Ensures organizational compliance with applicable laws and standards, and government regulations. Functions as an independent and objective body that reviews and evaluates compliance issues/concerns within the organization. Serves as a leader responsible for ensuring alignment with federal, state, and accrediting body requirements, including Centers for Medicare & Medicaid Services and The Joint Commission. Provides oversight of regulatory risk, and survey readiness strategy, in alignment with system Accreditation, regulatory and licensing strategic priorities. Responsible for designing, implementing, and optimizing regulatory program for the site that ensure continuous survey readiness, successful accreditation outcomes, and sustained compliance. Ensures the Board of Directors, senior management and employees are in compliance with the rules and regulations of regulatory agencies, and that company policies and procedures are being followed. Manages regulatory compliance through comprehensive assessment of organizational practices. Supervises and directs the activities of various levels of assigned personnel utilizing both professional and supervisory discretion and independent judgment. Manages large program(s) with substantial budget/impact.

Job Requirements:

Education and Work Experience:

• Bachelor's degree in nursing, business administration, hospital administration or equivalent combination of education/related experience: Required
• Three years' experience in healthcare: Required
• Two years' experience in accreditation or regulatory compliance or process improvements: Preferred
• Five years' experience in healthcare accrediation and regulatory affairs: Two years' leadership experience in Accreditation and Regulatory

Licenses/Certifications:

• Certified Professional in Healthcare Quality (CPHQ) or Healthcare Accreditation Certificated Professional (HACP) certification or Lean certification: Required within two years of hire
• Certified Professional in Healthcare Quality (CPHQ) or HACP or Lean or Six Sigma Green Belt (LGB): Required

Essential Functions:

• Reviews, interprets and assists hospital departments, leadership and Medical Staff in the implementation of Federal, State and Joint Commission standards and regulations. Maintains and controls all regulatory, licensure and accreditation documents. Monitors Joint Commission standards compliance. Conducts periodic internal reviews and/or audits to ensure compliance procedures are followed. Identifies regulatory compliance issues that require follow-up or investigation. Manages the internal investigations of compliance issues. Reviews operational risks and develops risk management strategies. Disseminates written policies and procedures related to regulatory compliance activities.
• Designs and implements systems to ensure a state of continual regulatory, licensure and accreditation compliance. Supports the accreditation preparation process for the organization by managing logistics, conducting mock surveys and maintaining organization's communication regarding changes and updates for regulatory compliance.
• Provides employee training on regulatory compliance related topics, policies or procedures. Provides assistance to internal or external auditors in regulatory compliance reviews. Prepares reports regarding regulatory compliance operations and progress. Monitors compliance systems to ensure effectiveness. Provides direction and assures regulatory compliance. Coordinates all on site regulatory, licensure and accreditation surveys, organizes schedules and conducts internal audit processes.
• Conducts annual State regulatory compliance assessment. Develops and maintains any action plan and response to citations for any regulatory agency. Collects data and prepares graphic presentation, and compiles reports to demonstrate compliance. Maintains and controls all regulatory, licensure and accreditation documents. Monitors Joint Commission standards compliance. Conducts periodic internal reviews and/or audits to ensure compliance procedures are followed. Identifies compliance issues that require follow-up or investigation. Manages the internal investigations of compliance issues.
• Prepares and submits reports following the review of unusual occurrences and adverse events in partnership with network manager or network director. Alerts appropriate regulatory bodies as required. Reviews unusual occurrences and adverse events, ensuring that immediate corrective actions are implemented for all reportable events to safeguard patient safety and regulatory compliance.
• Performs other job-related duties as assigned.

Organizational Requirements:

Adventist Health is committed to the safety and wellbeing of our associates and patients. Therefore, we require that all associates receive all required vaccinations as a condition of employment and annually thereafter, where applicable. Medical and religious exemptions may apply.