Accreditation and Regulatory Program Leader

Trinity Health • Livonia, MI

5d • $76,835 • Onsite

About The Position

Provides management and expertise in the areas of external regulatory compliance, and quality and patient safety standards as it relates to colleagues, medical staff, and inpatient/outpatient services. Collaborates with local and regional leadership to direct and coordinate the planning, implementation and evaluation of clinical process related to regulatory compliance. Leverages clinical information technology, process design, change management and evidence to ensure ongoing survey readiness and compliance with accreditation regulations and standards.

Requirements

• Bachelor's degree in nursing, pharmacy or other clinical or health care systems background.
• A minimum of five years clinical experience, including at least one to two years in leadership or management.
• Experience with and understanding of key functions of hospital and medical staff departments or services.
• Advanced interpersonal skills necessary to effectively communicate complex theoretical and technical concepts effectively with a wide variety of individuals.
• Advanced analytical and computer skills in order to manage project work and data.
• Advanced critical thinking skills necessary to develop sound recommendations and assist in implementing improved delivery of care systems, policies and procedures, evaluating clinical practice outcomes and developing educational programs.

Nice To Haves

• Master's degree in healthcare or healthcare-related field and Six Signma training at green belt or higher is preferred.
• Previous accreditation experience with an in-depth understanding of regulatory requirements and healthcare operations is preferred.
• Certificate as a Joint Commission Professional (CJCP) preferred.

Responsibilities

• Manages and directs the implementation of organization regulatory compliance activities across all areas, partnering with unit and program managers and leaders as appropriate.
• Leads the organization in pre-survey activities.
• Coordinates organizational response during CMS, state licensing surveys and Joint Commission surveys.
• Communicates survey results, develops action plans and survey responses in accordance with regulatory timelines.
• Manages complaint responses and associated action plans.
• Manages the routine and ongoing function of the accreditation software, Joint Communication extranet, and monitors the CMS.gov websites to assure compliance with regulatory reporting requirements.
• Utilizes performance improvement methodologies and change management strategies to address identified compliance gaps in regulations and standards.
• Strategizes with various levels of leadership to develop organization response to new regulations and standards with health system leadership.

Benefits

• Competitive compensation
• DAILYPAY Benefits effective Day One! No waiting periods.
• Full benefits package including Medical, Dental, Vision, PTO, Life Insurance, Short and Long-term Disability
• Retirement savings plan with employer match and contributions
• Opportunity for growth and advancement throughout Trinity Health
• Tuition Reimbursement

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level