AVP, Regulatory & Accreditation Services

Lifepoint Health • Brentwood, TN

1d • Remote

About The Position

At Lifepoint Health, we are committed to empowering and supporting a diverse and determined workforce who can drive quality, scalability, and significant impact across our hospitals and communities. As a member of the Health Support Center (HSC) team, you’ll support those that are in our facilities who are interfacing and providing care to our patients and community members to positively impact our mission of making communities healthier ®.
More about our team
The AVP, Regulatory and Accreditation Services- Behavioral Health surveys Lifepoint freestanding behavioral health facilities for regulatory and accreditation compliance. Applies systems analysis skills and inductive reasoning skills to determine health care organizations' degree of compliance with applicable standards and functionality of care delivery systems. Engages Lifepoint Health behavioral health facility staff in interactive dialogues on standards-based issues in health care to assess compliance and to identify opportunities for improving compliance.
Prepare regulatory and accreditation reports that link individual standards deficiencies with potential systems vulnerabilities and related organization risk points. Effectively communicates this information to Lifepoint Health facility leadership in a clear, concise and collegial style. Participates in other needed Regulatory & Accreditation activities as assigned by supervisor.

Requirements

• Applicants should have a current state RN license and possess a bachelor’s degree from an accredited nursing school with a minimum of 5 years of behavioral healthcare regulatory and accreditation experience with at least 5 of those years served in a managerial/supervisory or leadership role overseeing regulatory and accreditation.
• Current professional license in discipline required at time of hire and must be maintained.
• Strong background in freestanding behavioral healthcare regulatory and accreditation required
• Critical thinking, interpersonal, problem solving, interviewing, teamwork, organizational, and written and verbal skills required.
• Experience with team facilitation

Nice To Haves

• RN with a master's degree in healthcare administration/management (preferred behavioral health)
• CPHQ and/or CPPS preferred.

Responsibilities

• Demonstrates a thorough understanding of The Joint Commission (TJC), The Centers for Medicare and Medicaid Services (CMS), federal and state regulations
• Providing guidance and support, education, training and mentorship for CMS Conditions of Participation, accreditation, and survey readiness activities related to clinical quality, patient safety, infection prevention and control, organization performance and compliance with law, regulation and accreditation standards.
• Collaborate with the Hospital Operations – Clinical and Quality Teams and others in the Health Support Center office and at the local facility level in advancing high-quality, safety and clinical processes, regulatory and accreditation compliance to achieve positive patient outcomes and serve in the capacity of coach and mentor.
• Regulatory Compliance: Participates in Survey Readiness Assessments (SRAs) throughout the to assess and evaluate the facility’s actual performance of functions and processes aimed at continuously improving patient outcomes and their ability to provide safe, high-quality care.
• Provides resource for accreditation, CMS Conditions of Participation, performance improvement, patient safety, and infection control processes.
• Support and oversight and tracking for facilities to ensure compliance with local, state, and federal regulations.
• Accreditation Maintenance and Management: Support the process of applying for and maintaining accreditation.
• Audit Management: Coordinate internal audits, performing Survey Readiness Assessments to prepare facilities for surveys, and validating required documentation is complete and accurate.
• Policy Development: Participate in and support the development and maintenance of policies and procedures related to compliance, accreditation, and regulatory matters as needed.
• Training and Awareness: Train Quality staff on regulatory requirements and ensure ongoing compliance through regular meetings or training sessions. In addition, provide support and education as needed, to other departments or leaders.
• Reporting and Documentation: Maintain up-to-date tracking records, reports and correction plans for regulatory bodies; validate documentation for audits, inspections, and compliance assessments; Provide guidance and review correction plans to ensure credible, robust actions that will facilitate compliance.
• Liaison with Leadership and Regulatory Bodies: Serve as the point of contact between the HSC leadership and the facilities regarding relevant regulatory and accreditation matters, as well as a contact for regulatory bodies to ensure accuracy and consistency.

Benefits

• Comprehensive Benefits: Multiple levels of medical, dental and vision coverage for full-time and part-time employees.
• Financial Protection & PTO: Life, accident, critical illness, hospital indemnity insurance, short- and long-term disability, paid family leave and paid time off.
• Financial & Career Growth: Higher education and certification tuition assistance, loan assistance and 401(k) retirement package and company match.
• Employee Well-being: Mental, physical, and financial wellness programs (free gym memberships, virtual care appointments, mental health services and discount programs).
• Professional Development: Ongoing learning and career advancement opportunities.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 101-250 employees