Manager - Accreditation and Regulatory Affairs

Position Objective:

Under the direction of the VP, Quality & Patient Safety, the Manager develops and implements organizational initiatives to support Luminis Health (LH) accreditation and regulatory continuous readiness. The Manager will work with the LH acute care hospitals, clinicians, clinical support and other health system leaders on the continuous readiness program and ongoing 1) Standard interpretation, 2) Standard compliance, 3) Education and communication about regulatory affairs, and 4) Survey operations. The Manager emphasizes quality and patient safety at the forefront of regulatory compliance and oversees the day-to-day department program operations and workflow. The Manager directly supervises Accreditation and Regulatory Specialists and is expect to split time on-site at both of the acute care hospitals

Essential Job Duties:

1. Proactively leads the ongoing evaluation, planning and support of the LH continuous readiness infrastructure and processes to ensure accreditation by deemed status accrediting organizations such as The Joint Commission, CMS, Office of Healthcare Quality, as well as other regulatory accreditation, certifications, and applicable organizational licenses.

2. Supports workflow needs and develops strengths of content experts and other accreditation and regulatory leaders to support workflow accordingly. Serves as the system accreditation leader during any on-site survey.

3. Manages system and entity Accreditation and Regulatory Readiness Committees and provides oversight for the accreditation and regulatory specialists to review work plans and progress. Identifies growth and areas of opportunity to ensure Program initiatives are being met.

4. Provides guidance on accrediting and certification standards interpretation and other regulatory requirements as they apply to organizational practice.

5. Educates leaders, staff, medical staff and other stakeholders on the accreditation process and requirements.

6. Partners with regulatory content experts to identify risk areas and support development, implementation and monitoring of regulatory improvement processes.

7. Ensures regulatory resources are up to date, such as Accreditation Manager Plus (AMP) software program, E-dition standards, and links to the CMS CoPs Interpretive Guidelines and other applicable regulations.

8. Develops and implements initiatives to enhance process improvements, and evaluate and monitor compliance with regulatory standards through ongoing organizational assessment, i.e. lntracycle Monitoring, Focused Standards Assessment, tracers, mock surveys and measurement data.

9. Finalizes and submits corrective action responses to regulatory agencies for survey and for-cause and compliant investigations.

10. Serves as contact and point person for applicable standards-related manuals, publications and newsletters and educational materials; ensures pertinent information is communicated to appropriate individuals.

11. Serves as a liaison between accreditation/ regulatory bodies and the organization.

Educational/Experience Requirements:

• Bachelor's degree in nursing, Healthcare Administration, Healthcare Information Management, or a related field, or equivalent combination of experience and education.

• Two (2) years of experience in management or leadership role within a large hospital or health system.

• Expert knowledge of the regulatory environment to include The Joint Commission, CMS, and the National Committee for Quality Assurance.

• Two years' experience with accreditation and regulatory standards and activities, including the survey process and follow up of corrective action plans.

• Proficiency in using Microsoft Office (Outlook, Teams, Excel, Word, and PowerPoint) and AMP.

• Strong analytic, project management, and problem-solving skills.

• Excellent communication skills (oral, electronic, and written), including public speaking

• Requires critical thinking skills, decisive judgment, and the ability to work with minimal supervision.

• Additional certification in healthcare quality from a recognized organization preferred

Working Conditions, Equipment, Physical Demands:

There is a reasonable expectation that employees in this position wiII be exposed to blood-borne pathogens.

Physical Demands - Light

Light work - Exerting up to 20 pounds of force occasionally, and/or up to10 pounds of force frequently, and/or a negligible amount of force constantly to move objects. If the use of arm and/or leg controls requires exertion of forces greater than that for sedentary work and the worker sits most of the time, the job is rated for light work.