Manager of Accreditation and Regulatory Information, Accreditation and Medical Library, Full-Time, Days

MarinHealth•Greenbrae, CA

1d•$54 - $81•Onsite

About The Position

MarinHealth is an integrated, independent healthcare system seeking a Manager of Accreditation and Regulatory Information. This role is crucial for developing and managing data systems that support ongoing regulatory compliance, particularly with The Joint Commission standards and other state and federal requirements. The position involves analytical and project management work, coordinating assessments, measurements, and reporting to ensure compliance. MarinHealth is a growing organization with a new state-of-the-art hospital and a network of clinics, recognized for its high quality of care and commitment to innovation.

Requirements

Bachelor’s degree required.
Five years experience in a management or leadership role within a hospital or health care organization with responsibility for accreditation and regulations related to healthcare.
Knowledge of Joint Commission standards and survey process.
Excellent analytical, project management and independent problem-solving skills.
Ability to review medical records and abstract pertinent clinical and other information using regulatory assessment tools, audits and monitoring activities.
Ability to work with others in developing appropriate data collection and assessment tools to support compliance activities in response to dynamic regulatory requirements.
Knowledge of Word, Excel, and PowerPoint software programs or equivalents.
Excellent communication skills (oral, electronic and written).
Ability to demonstrate excellent judgment, attention to process and detail.
Demonstrates ability to apply discretion, confidentiality, tact, and ability to deal with sensitive issues.
Demonstrates ability to work independently, and ability to work interdependently.
Demonstrates evidence of continuing professional development.
Demonstrates excellent customer service skills.
Ability to set priorities and manage multiple demands effectively.
Ability to function autonomously and take initiative.
Ability to work collaboratively with hospital staff, physicians, and outside agencies.
Ability to manage change through collaborative and positive leadership skills.
Ability to take initiative in leading the organization while being a team player and can work as a team member across organization lines.
Demonstrates ability to communicate effectively with executives, physicians, directors, managers, and staff.
Demonstrates excellent organizational skills.
Demonstrates ability to interact with all levels of staff and management, and ability to set priorities and mange multiple demands effectively.
Clearly and effectively communicates on the telephone, in person, and in memoranda and effectively presents materials and findings to appropriate audiences.

Nice To Haves

Responsibilities

Manages and collaborates with the Director Quality Management Services in the development and management of data systems that support ongoing regulatory compliance.
Performs analytical and project management work that supports the function of the Accreditation program.
Manages and coordinates the assessment, measurement, and reporting of ongoing compliance with the Joint Commission accreditation standards and other state and federal regulatory requirements.
Works with the Director, Quality Management Services to develop appropriate data collection and assessment tools to support compliance activities in response to dynamic regulatory requirements.
Oversees and leads the Continuous Readiness team. Develops and timely submits the Periodic Performance Review, and supports Chapter leaders in implementation of new and revised standards.
Acts as a trusted resource and guidance leader for Federal, State and local regulatory agencies (e.g. CMS, OSHPD, etc.) and accrediting agency requirements to ensure compliance.
Manages ongoing tracer activities in collaboration with other departments using a standardized set of tools and methodologies.
Provides timely feedback about findings and staff performance to the appropriate manager or designee of the areas in which tracers are conducted.
Synthesizes data and other information into summary format in a logical and systematic manner to facilitate conclusions and recommendations.
Enters and verifies data collected into databases and web-based applications.
Analyzes and reports findings and utilizes tracer tools and process to identify and report system issues and evaluate effectiveness of corrective actions and improvement strategies both as a participant and influencer in continuous improvement activities.
Manages and distributes a Joint Commission scorecard across the organization.
Directly supports the continuous readiness activities in the preparation, organization and maintenance of documents related to project management, meeting agendas and materials, action plans and reports.
Participates in the design and development of Joint Commission related and other regulatory driven education curricula, materials, tools and instructional methodologies.
Interfaces with executives to develop work plans for, and track progress on, The Joint Commission Readiness Plan and aspects of the Operations that pertain to regulatory compliance.
Strives for continuous professional development in maintaining and increasing knowledge and skills related to regulatory requirements.
Liaison to California Department of Public Health Services for all licensing related activities, including but not limited to General Acute Care Hospital surveys, and event investigations.
Supports content experts in ensuring licensure applications and compliance.
Develops and monitors operational, capital, and staffing budgets.
Develops and maintains policies and procedures related to accreditation and regulations.
Works in cooperation with Community Relations Department to plan/coordinate promotional materials and events related to accreditation.
Manages and maintains regulatory status of House-wide Administrative and Clinical policies and procedures and assists with approval process of departmental policies and procedures.
Manages and maintains regulatory status of hospital forms.
Other duties as assigned.