Senior Accreditation and Regulatory Readiness Specialist

Brown Medicine • Los Angeles, CA

3d • Hybrid

About The Position

Work on a team that supports all aspects of The Joint Commission Accreditation Standards and Centers for Medicare and Medicaid Services conditions of participation compliance as well as Department of Health Regulations, Centers of Excellence, Certification and other related external regulatory, accreditation and certification requirements. Independently collaborates and coordinates review of accreditation and regulatory opportunities with Risk Management, Care Transformation, Quality and Safety, and with other quality initiatives and committees. Monitor overall performance metrics related to regulatory and accreditation standards. Responsible for achieving improved performance against standards. Collaborate with lead stakeholders to develop tracers and report to monitor compliance with standards. Lead regulatory readiness monthly meetings. Educate staff regarding regulatory requirements and standards interpretation. Participate in Environmental Rounds to identify and resolve safety issues and noncompliance with regulatory standards. Participate in survey preparation, actual survey and post survey activities. Facilitate creation of corrective action plan with hospital senior leaders. Maintain the collection and analysis of meaningful information for guiding improvement efforts in the AMP tracer auditing database.

Requirements

• Bachelor’s Degree in Health Administration, Nursing, or related Healthcare Professional field.
• Must be a Certified Professional in Healthcare Quality (CPHQ) or equivalent.
• 2 years of experience in leading organization accreditation including managing and supporting accreditation by The Joint Commission and Centers for Medicare and Medicaid Services.
• 2 years of experience in leading development of system wide projects to improve regulatory activity.
• 2 years of experience in creating analytical audit tools, reports, and analyzing data trends to inform performance improvement activities.
• 2 years of experience in guiding organizational leaders and creating presentations using Microsoft PowerPoint to educate staff regarding The Joint Commission Accreditation Standards and Centers for Medicare and Medicaid Services, Department of Health Regulations, Centers of Excellence, Certification and other related external regulatory requirements and standards interpretation.
• 2 years of experience in navigating The Joint Commission Connect portal to enter applications, review invoices, review regulatory activity and submit corrective actions plans.
• Position requires travel to Brown University Health affiliated hospitals at least once per month.

Responsibilities

• Collaborates and coordinates review of accreditation and regulatory opportunities with Risk Management, Care Transformation, Quality and Safety, and with other quality initiatives and committees.
• Monitors overall performance metrics related to regulatory and accreditation standards.
• Achieves improved performance against standards.
• Collaborates with lead stakeholders to develop tracers and report to monitor compliance with standards.
• Leads regulatory readiness monthly meetings.
• Educates staff regarding regulatory requirements and standards interpretation.
• Participates in Environmental Rounds to identify and resolve safety issues and noncompliance with regulatory standards.
• Participates in survey preparation, actual survey and post survey activities.
• Facilitates creation of corrective action plan with hospital senior leaders.
• Maintains the collection and analysis of meaningful information for guiding improvement efforts in the AMP tracer auditing database.

Benefits

• Equal employment opportunities

What This Job Offers

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