Regulatory Accreditation Program Manager

HonorHealth•Scottsdale, AZ

1d•Onsite

About The Position

Provides operational support and management for federal certification, state licensure, and accreditation compliance programs within HonorHealth. Under the direction of the AVP Regulatory/Accreditation, develops, implements, manages, and maintains comprehensive programs and projects. Provides consultation, education, and teaching to leadership, medical staff, and external customers to strengthen network performance in regulatory and accreditation compliance. Initiates and leads improvements to ensure continual compliance with applicable standards and works closely with Nursing and the Patient Safety Program on performance improvement activities. Ensures network-wide compliance with federal certification and state licensing regulations and accrediting body standards. Serves as the entry point for regulatory and accreditation issues involving network outpatient center compliance; leads clinical compliance teams; coordinates preparation for scheduled and unannounced surveys; and serves as a clinical compliance expert during on-site surveys. Assesses clinical and non-clinical performance, identifies potential or actual patient safety issues, and coordinates corrective and preventive action. Collaborates with facility and Quality staff, responds to deficiencies, and ensures reporting deadlines and data meet current requirements. Leads clinical quality and continuous improvement teams addressing corrective action plans arising from accreditation, licensing, and complaint surveys. Supports leaders in executing and sustaining PDSA plans. Facilitates education for nursing and other clinical personnel, including leadership, on regulatory and accreditation processes and network performance improvement activities. Serves as a network clinical lead for the ISO internal audit process, operationalizing the function by maintaining an annual audit schedule, ensuring key processes are audited at least annually, trending quarterly results, and submitting regular summaries to the network ISO Management Representative. Participates in developing network policies and strategies informed by quality-of-care issues and regulatory and accrediting standards.

Requirements

Bachelor’s degree in nursing (BSN), an advanced degree, or equivalent in a healthcare field or related discipline (such as Pharmacy, MD, or DO) is required.
At least 1 year of regulatory/accreditation compliance experience is required.
At least 2 years of quality improvement or program/project experience is required.

Nice To Haves

Master’s degree preferred.
At least 5 years of regulatory/accreditation compliance experience in a healthcare environment preferred.
At least 5 years of quality improvement or program/project experience preferred.
Arizona license as an RN, Pharmacy professional, or holder of an advanced degree (MPH, MD, DO) preferred.
Certified Professional in Healthcare Quality (CPHQ) preferred.

Responsibilities

Ensure continual network-wide compliance with federal certification and state licensing regulations and accrediting body standards.
Serve as the entry point for regulatory and accreditation issues related to network outpatient center compliance.
Lead clinical regulatory and accreditation compliance teams.
Coordinate preparation for scheduled and unannounced regulatory and accreditation surveys and serve as the clinical compliance expert during on-site surveys.
Assess clinical and non-clinical performance and identify potential or actual patient safety issues.
Coordinate corrective and preventive actions when improvement opportunities are identified, working collaboratively with facility and Quality staff.
Respond to regulatory and accreditation deficiencies and ensure reporting deadlines are met and submitted data meet current requirements.
Lead clinical quality and continuous improvement teams addressing corrective action plans from accreditation, licensing, and complaint surveys.
Consult with and support clinical and non-clinical leadership in executing and sustaining PDSA plans.
Facilitate education for nursing and other clinical personnel, including leadership, on regulatory and accreditation processes and performance improvement activities.
Operationalize the ISO internal auditing function, maintain an annual audit schedule, ensure key processes are audited at least annually, and compile and trend quarterly audit results.
Submit regular summaries of internal audit results to the network ISO Management Representative.
Participate in formulating and designing network policies and strategies informed by quality-of-care issues and regulatory and accrediting agency standards.