Accreditation and Policy Manager

Kenaitze Indian Tribe•Kenai, AK

1d•Onsite

About The Position

The Accreditation and Policy Manager is responsible for the monitoring and maintaining the Kenaitze Indian Tribe's (the Tribes) policies, procedures, standard work, forms, Charters, Ordinances, and other documents. The Accreditation and Policy Manager ensures that all documents in the system are managed by responsible leaders in accordance with Federal, State, and accrediting bodies to maintain certification and licensure. Recommendations for documents will meet or exceed best practice principles, encouraging staff to provide quality and safe care for our patients/clients (un'ina). The Accreditation and Policy Manager will take a lead role in collaborating with department heads in maintaining continual compliance with Commission on Accreditation of Rehab Facilities (CARF) standards. Responsible for exploring and pursuing other accreditation, as appropriate, to ensure the Tribe maintains the highest possible service delivery standards.

Requirements

Bachelor's Degree in healthcare or related field, or a combination of education and experience may be substituted for a degree
Two (2) years of experience in policy development or policy management in a healthcare setting
Two (2) years of experience leading a healthcare system to achieve successful accreditation
Must have a valid Alaska State driver's license and must remain insurable under the Tribe's policy
Proven ability to work on several projects simultaneously and under tight schedules
Strong interpersonal skills
Excellent problem-solving skills
Excellent writing skills with the ability to create business/healthcare documents
Strong knowledge of medical terminology and procedures to address nursing, medical, and BH provider issues related to policies, procedures, etc.
Knowledge of Medicaid and National healthcare compliance regulations and practices
Experience with Survey prep for accrediting bodies such as CARF, AAAHC, etc.
Conducts business in a service-oriented manner that is attentive, pleasant, respectful and kind when dealing with un'ina, visitors, co-workers and others
Ability to work independently as well as collaboratively
This position is a Covered Position subject to all requirements of the Alaska Barrier Crimes Act (ABCA) and to the Indian Child Protection and Family Violence Prevention Act, (ICPA). ABCA and ICPA requirements apply and must be complied with at all times in order to remain in the position.

Responsibilities

Conducts regular monitoring, development and training of the policy management system.
Collaborates with department managers providing education and guidance regarding effective development of documents
Ensures that all regulatory required documents remain active in the system and reflect changes imposed by the regulatory bodies
Participates in and/or co-facilitates workgroup meetings for policy development and accreditation compliance
Completes and documents quarterly updates on the Annual Quality Assurance/Performance Improvement (QAPI) work plan
Maintains continual accreditation survey readiness by conducting mock surveys and audits, and developing corrective action plans to address any findings
Communicates obstacles to Director of Quality, Compliance & Privacy in a timely manner.
Prepares documents for external surveys/reviews, compliance plan and quality improvement plans
Coordinates and delivers staff education
Leads policy and accreditation planning sessions with departments as needed
Stays current with healthcare regulations and standards
Seeks continuing education opportunities with the Institute for Healthcare Improvement (IHI), the National Association for Healthcare Quality (NAHQ) or any other professional organizations as applicable
Ensures compliance with Tribal, federal, state, and local employment laws and regulations, Tribal policies and TERO ordinance