Manager Accreditation & Compliance RN

Trinity Health • Fresno, CA

8d • Onsite

About The Position

This position provides management and expertise in the areas of accreditation and regulatory compliance, as it relates to colleagues, medical staff, and inpatient and outpatient services for Saint Agnes Medical Center (SAMC). This role is responsible for planning, developing, implementing and evaluating the overall Saint Agnes Continuous Regulatory Readiness program and survey activity. Position oversees tracking and supporting regulatory survey processes throughout Saint Agnes, including Triennial Joint Commission accreditation and specialty accreditation (initial or reverification). Fosters and supports a culture of continuous improvement and coordinates the systematic implementation of effective practices designed to reduce error and improve patient outcomes cohesively across the system. Work collaboratively with leadership, management, medical staff, and interdisciplinary staff across the entire organization. Provides day-to-day oversight of the programs including personnel management, deployment of resources, project management, evaluation of processes, analysis of data, and continuous regulatory readiness. The incumbent will leverage clinical information technology, process design, change management and evidence-based leading practices to support optimal quality outcomes, improve data-driven performance and promote ongoing survey readiness and compliance with accreditation regulations and standards. This position also supports specific initiatives related to external certification or recognition as reflected in the organization's strategic quality and safety priorities.

Requirements

• Must possess a comprehensive knowledge of regulatory readiness, standards interpretation, and project management, management, and training and development in regulatory preparations.
• Bachelor’s degree in Health Administration, Nursing or a related field is required with five (5) years of quality or regulatory experience or an equivalent combination of education and experience.
• Current licensure as a Registered Nurse (RN) or other clinical licensure in the State of California is required.
• Experience in interpreting and advising regarding regulatory and accreditation standards.
• Strong verbal and written communication skills are required. Ability to present information in a confident, clear, concise, and articulate manner is required.
• Proficiency in using Microsoft Office products, including Excel and PowerPoint, and various other computer software products is required.

Nice To Haves

• Experience in decision-making, leadership and in-depth knowledge, safety, is preferred.
• Master's degree is preferred.

Responsibilities

• Planning, developing, implementing and evaluating the overall Saint Agnes Continuous Regulatory Readiness program and survey activity.
• Overseeing tracking and supporting regulatory survey processes throughout Saint Agnes, including Triennial Joint Commission accreditation and specialty accreditation (initial or reverification).
• Fostering and supporting a culture of continuous improvement and coordinating the systematic implementation of effective practices designed to reduce error and improve patient outcomes cohesively across the system.
• Working collaboratively with leadership, management, medical staff, and interdisciplinary staff across the entire organization.
• Providing day-to-day oversight of the programs including personnel management, deployment of resources, project management, evaluation of processes, analysis of data, and continuous regulatory readiness.
• Leveraging clinical information technology, process design, change management and evidence-based leading practices to support optimal quality outcomes, improve data-driven performance and promote ongoing survey readiness and compliance with accreditation regulations and standards.
• Supporting specific initiatives related to external certification or recognition as reflected in the organization's strategic quality and safety priorities.

Benefits

• Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.

What This Job Offers

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