Regulatory Accreditation Program Manager

Four Peaks Medical Center - 1301 S Crismon Rd, Mesa, AZ 85209. Category: Operations. Shift: Day. Department: Quality Improvement Division. Full Time, Mon‑Fri.

About the role

Great care starts with great people. (Like you.) At HonorHealth, you’ll find something special. From humble beginnings in 1927 to one of Arizona’s largest nonprofit healthcare systems, our culture is built on warmth and neighborly kindness. Behind every smile is a highly skilled professional with deep expertise and an unwavering dedication to what matters most — caring for the health and well-being of people and communities across the greater Phoenix area.

Responsibilities

• Provides operational support and management for federal certification, state licensure, and accreditation compliance programs within HonorHealth.
• Under direction of AVP Regulatory/Accreditation, develops, implements, manages and maintains comprehensive programs and projects and provides consultation, education and teaching to leadership, medical staff, and external customers to strengthen network performance in regulatory/accreditation compliance.
• Initiates/leads necessary improvements to ensure continual compliance with applicable regulatory and accreditation standards.
• Works closely with Nursing and Patient Safety Program on performance improvement activities leading to continual performance improvement.
• Ensures continual network-wide compliance with federal certification and state licensing regulations and accrediting body standards.
• Serves as the entry-point for regulatory/accreditation issues in maintaining network outpatient center compliance.
• Leads clinical regulatory and accreditation compliance teams.
• Coordinates the preparation for regulatory and accreditation surveys to maintain HonorHealth in a state of continual readiness for scheduled and unannounced surveys.
• Serves as the clinical compliance expert during on-site surveys.
• Assesses current clinical and non-clinical performance and identifies potential or actual patient safety issues.
• Coordinates corrective and preventive action when opportunities for improvement are identified.
• Works in a collaborative manner with facility staff as well as associated Quality staff for improvement.
• Responds effectively to regulatory and accreditation deficiencies.
• Assures reporting deadlines are met and data reported are consistent with current requirements to maintain good standing with accrediting/regulatory agencies.
• Leads clinical quality and continuous improvement teams related to corrective action plans arising out of accreditation, licensing, and complaint surveys.
• Consults with and supports clinical and non-clinical leadership in executing and sustaining PDSA plans.
• Facilitates education programs to provide innovative learning experiences for all levels of nursing and