Director Accreditation and Regulatory Compliance
About The Position
The Director of Accreditation and Regulatory Compliance has primary responsibility for the development, implementation and enforcement of clinical accreditation and regulatory compliance programs. They work to ensure conformance with applicable state and federal laws, regulations and accreditation standards which will include, but are not limited to, The Joint Commission (TJC), Title 22, CMS Conditions of Participation and the California Department of Public Health (CDPH). This role is responsible for leading continuous, organizational regulatory readiness and compliance to regulatory and accreditation standards. They coordinate verbal and written communication with The Joint Commission (TJC) and other regulatory bodies. Works closely with medical staff, nursing/hospital staff, and department directors and managers to ensure ongoing regulatory and accreditation readiness and compliance. Works in collaboration with key members of the organization to conduct compliance monitoring reviews and develops corrective action plans in response to review findings. Coordinates and participates in the execution of educational activities and the development of educational materials for continuous readiness preparation at all levels of staff, including nursing, other patient care providers, other non-clinical hospital staff as appropriate, Medical Staff and Administration. In collaboration with the Quality Management Department, performs pro-active risk assessment and facilitates design and implementation of action plans.
Requirements
- A minimum of two (2) years’ clinical experience plus two (2) years’ managerial experience in an acute care hospital setting required.
- Previous successful experience as Director or Manager responsible for hospital’s accreditation and regulatory readiness required.
Nice To Haves
- Current California Registered Nurse license preferred.
Responsibilities
- Plans, assigns and directs department workflow.
- Prepares employee annual performance appraisals.
- Addresses and resolves departmental staff complaints and proactively manages department production and quality control efforts.
- Sets the standard for departmental behavior and provides and promotes a positive working environment for departmental staff to ensure strong employee morale, motivation and productivity.
- Holds accountability for the departmental budget and Position Control and takes necessary action to remain within balance and address variances.
- Responsible for leading continuous, organizational regulatory readiness and compliance to regulatory and accreditation standards.
- Coordinates verbal and written communication with The Joint Commission (TJC) and other regulatory bodies.
- Works closely with medical staff, nursing/hospital staff, and department directors and managers to ensure ongoing regulatory and accreditation readiness and compliance.
- Works in collaboration with key members of the organization to conduct compliance monitoring reviews and develops corrective action plans in response to review findings.
- Coordinates and participates in the execution of educational activities and the development of educational materials for continuous readiness preparation at all levels of staff, including nursing, other patient care providers, other non-clinical hospital staff as appropriate, Medical Staff and Administration.
- In collaboration with the Quality Management Department, performs pro-active risk assessment and facilitates design and implementation of action plans.
- Performs other duties as assigned.
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What This Job Offers
Job Type
Full-time
Career Level
Director
