Accreditation and Regulatory Program Leader

Full-time, day shift position located in Livonia.

About the Role

Provides management and expertise in external regulatory compliance, quality, and patient safety standards as they relate to colleagues, medical staff, and inpatient/outpatient services. Collaborates with local and regional leadership to direct and coordinate the planning, implementation, and evaluation of clinical processes related to regulatory compliance. Leverages clinical information technology, process design, change management, and evidence to ensure ongoing survey readiness and compliance with accreditation regulations and standards.

Responsibilities

• Manages and directs the implementation of organization regulatory compliance activities across all areas, partnering with unit and program managers and leaders as appropriate.
• Leads the organization in pre-survey activities.
• Coordinates organizational response during CMS, state licensing surveys, and Joint Commission surveys.
• Communicates survey results, develops action plans, and survey responses in accordance with regulatory timelines.
• Manages complaint responses and associated action plans.
• Manages the routine and ongoing function of the accreditation software, Joint Commission extranet, and monitors the CMS.gov websites to assure compliance with regulatory reporting requirements.
• Utilizes performance improvement methodologies and change management strategies to address identified compliance gaps in regulations and standards.
• Strategizes with various levels of leadership to develop organization response to new regulations and standards with health system leadership.

Requirements

• Bachelor's degree in nursing, pharmacy, or other clinical or healthcare systems background.
• Master's degree in healthcare or healthcare-related field and Six Sigma training at green belt or higher is preferred.
• A minimum of five years of clinical experience, including at least one to two years in leadership or management.
• Experience with and understanding of key functions of hospital and medical staff departments or services.
• Previous accreditation experience with an in-depth understanding of regulatory requirements and healthcare operations is preferred.
• Certificate as a Joint Commission Professional (CJCP) preferred.

Skills

• Advanced interpersonal skills necessary to effectively communicate complex theoretical and technical concepts with a wide variety of individuals.
• Advanced analytical and computer skills to manage project work and data.
• Advanced critical thinking skills to develop sound recommendations and assist in implementing improved delivery of care systems, policies, and procedures, evaluating clinical practice outcomes, and developing educational programs.

Benefits

• Competitive compensation with DailyPay option.
• Benefits effective day one with no waiting periods.
• Full benefits package including medical, dental, vision, PTO, life insurance, short- and long-term disability.
• Retirement savings plan with employer match and contributions.
• Opportunity for growth and advancement throughout Trinity Health.
• Tuition reimbursement.

Schedule

Full-time, 40 hours per week, day shift.