Accreditation Program Manager - Quality Care Management

Providence•Richland, WA

About The Position

Under the general supervision of the Director of Quality, the Regulatory Readiness Program Manager exercises independent decision-making and applies knowledge of organizational policies and procedures. The role supports preparation for regulatory surveys and monitors standards compliance for hospitals and clinics covered under licensure, in alignment with health-care accreditation and non-financial regulatory requirements. The program manager communicates compliance information to department leaders and staff, recommends actions to maintain or exceed standards, and facilitates collaboration with departmental leaders to assess compliance and establish action plans for areas of focus or non-compliance. The role organizes survey-readiness frameworks and site-visit preparations for surveys and accreditation processes, and serves as a resource and content expert on standards and regulations for operational leaders. The position is part of Kadlec Regional Medical Center and supports Providence’s patient-focused, whole-person care culture.

Requirements

Graduation from an accredited nursing program.
Bachelor’s degree in Nursing, or a Bachelor’s degree in Nursing in progress; if in progress, it must be completed within three years from the date of hire.
Five years of recent acute-care or ambulatory RN experience.

Nice To Haves

Master’s degree.
Two years of performance-improvement process experience.
Two years of experience working with The Joint Commission standards, DOH regulations, and compliance.
Experience with project and/or team facilitation, adult education, and policy development and analysis.
Experience with software applications, including word processing, Excel, and Access.

Responsibilities

Assist in preparation for regulatory surveys.
Monitor standards compliance for hospitals and clinics covered under licensure, in alignment with health-care accreditation and non-financial regulatory requirements.
Communicate necessary information to appropriate department leaders and staff and recommend actions to maintain or exceed compliance with standards.
Facilitate and collaborate with departmental leaders to assess standards compliance in their areas and ensure action plans are in place for areas of focus or non-compliance, without assuming ownership of those action plans.
Organize the survey-readiness framework and site-visit preparations for surveys and accreditation processes.
Serve as a resource to operational leaders and as a content expert in standards and regulations.