Your Role on the Team

Position Summary:
Supports the coordination of accreditation, regulatory, and licensing activities for UCI Health. The incumbent independently performs a wide range of functions related to the Medical Center's Regulatory Compliance Program including the submission of necessary documentation to regulatory/accreditation entities such as the California Department of Public Health (CDPH), The Joint Commission (TJC), and Centers for Medicare and Medicaid (CMS). Involves the review and evaluation of healthcare regulatory compliance controls and programs. Develops regulatory policies and systems from a strategic perspective; keeps abreast of regulatory issues, plans for changes and / or integration as new healthcare affiliations are assumed. Provides education and consultation to hospital and medical staff regarding the integration of compliance regulatory standards with programs and operations. Acts as a channel of communication to direct compliance issues to appropriate resources for investigation and resolution.

What It Takes to be Successful

Required Qualifications:

Strong knowledge of CMS Conditions of Participation, Federal and State (Titles 22 & 24) regulations, and The Joint Commission accreditation standards. experience in a key role in CMS and Joint Commission surveys

Strong analytical skills to comprehend complex reports and provide an analysis to support actionable decision making

Must possess the skill, knowledge and ability essential to the successful performance of assigned duties

Must have excellent presentation and computer skills

Must demonstrate customer service skills appropriate to the job

Must be able to work flexible hours and locations based on the organization's needs

Minimum of five years' experience in a quality or regulatory compliance role within a hospital or health care organization

Excellent written and verbal communication skills in English

Effective written and verbal communication skills; ability to communicate with customers/staff with diverse educational backgrounds

Demonstrated ability to problem solve, think critically and creatively, and provide leadership through a consultative role

Bachelor's Degree in a health-related field, RN, or equivalent experience in Quality & Patient Safety

Ability to manage numerous diverse projects simultaneously through effective priority setting

Ability to maintain a work pace appropriate to the workload

Ability to establish and maintain effective working relationships across the Health System

Ability to be self-directed and function independently with minimal supervision/direction

Preferred Qualifications:

Recent experience leading a CMS or Joint Commission survey

Master's Degree in health related field

Knowledge of University and medical center organizations, policies, procedures and forms

Current RN License

Total Rewards

We offer a wealth of benefits to make working at UCI even more rewarding. These benefits may include medical insurance, sick and vacation time, retirement savings plans, and access to a number of discounts and perks. Please utilize the links listed here to learn more about our compensation practices and benefits.

Conditions of Employment:

The University of California, Irvine (UCI) seeks to provide a safe and healthy environment for the entire UCI community. As part of this commitment, all applicants who accept an offer of employment must comply with the following conditions of employment:

• Background Check and Live Scan
• Employment Misconduct*
• Legal Right to Work in the United States
• Vaccination Policies
• Smoking and Tobacco Policy
• Drug Free Environment

Exercise the utmost discretion in managing sensitive information learned in the course of performing their duties. Sensitive information includes but is not limited to employee and student records, health and patient records, financial data, strategic plans, proprietary information, and any other sensitive or non-public information learned during the course and scope of employment. Understands that sensitive information should be shared on a limited basis and actively takes steps to limit access to sensitive information to individuals who have legitimate business need to know. Ensure that sensitive information is properly safeguarded. Follow all organizational policies and laws on data protection and privacy. This includes secure handling of physical and digital records and proper usage of IT systems to prevent data leaks. The unauthorized or improper disclosure of confidential work-related information obtained from any source on any work-related matter is a violation of these expectations.

*Misconduct Disclosure Requirement: As a condition of employment, the final candidate who accepts a conditional offer of employment will be required to disclose if they have been subject to any final administrative or judicial decisions within the last seven years determining that they committed any misconduct; received notice of any allegations or are currently the subject of any administrative or disciplinary proceedings involving misconduct; have left a position after receiving notice of allegations or while under investigation in an administrative or disciplinary proceeding involving misconduct; or have filed an appeal of a finding of misconduct with a previous employer.

The following additional conditions may apply, some of which are dependent upon business unit or job specific requirements.

• California Child Abuse and Neglect Reporting Act
• E-Verify
• Pre-Placement Health Evaluation

Details of each policy may be reviewed by visiting the following page: https://hr.uci.edu/new-hire/conditions-of-employment.php

Consideration for Work Authorization Sponsorship

Must be able to provide proof of work authorization