Director of Accreditation and Regulatory- Full Time Days

About the role

Responsible for managing accreditation, certification and regulatory compliance and survey activities in conjunction with the Corporate Director of Quality and Patient Safety.

Responsibilities

• Leads Corporate Leapfrog initiatives and ensures that all facilities are tracking these measures for success
• Leads the organization in Readmission Reduction Program in collaboration with leadership
• Participates in processes that assure local, regional/market and corporate standards that dictate care, patient safety and clinical practices as outlined in policies, procedures, forms, and other documents.
• Participates in Corporate, Disease Specific Certifications.
• Implement and assist with projects related to clinical quality improvement (QI), quality measurement and QI research in the Division of Quality and Patient Safety.
• Works with the Quality team to develop activities related to VBP, HAC, HRRP, Care Compare data to decrease financial implications.
• Works with all levels of leadership and front-line staff to facilitate and support the development and integration of evidence-based best practices at the department/program level.
• Review of corporate policies and procedures to ensure regulatory compliance.
• Assessment of corporate compliance and submission of Leapfrog survey
• Actively participates in regulatory surveys to provide relevant data as necessary and maintains constant preparation.
• Data collection, database development and basic statistical analyses from information gathered in patient surveys, electronic health records, hospital administrative databases, and other sources.
• Other duties as assigned

Requirements

• Bachelor’s degree in nursing, computer science or other healthcare related field required
• 3 years of healthcare related experience required
• Experience in working with The Joint Commission and CMS standards preferred
• Working knowledge of EPIC, Press Ganey, BI, Premier, Microsoft Office, and SPSS preferred

Qualifications

• Certification (CPHQ), American Society for Quality (ASQ) or other related quality certification preferred

Skills

• Proficiency in reading, writing and speaking the English language
• Knowledge of theories, principles, and methods utilized in the development of health quality databases and analysis of health quality data preferred
• Knowledge of survey, accreditation and regulatory processes required
• Must be independent, efficient and have exceptional interpersonal skills, as interaction with patients, families, and medical staff is necessary
• Must be able to move throughout the Health System without difficulty, stand and sit for long periods of time