Manager accreditation

Position Summary:

Responsible for overall accountability for the assigned facility’s accreditation and regulatory requirements including active involvement with all survey activity. Leads facility and associated on and off-campus site activities to achieve a constant state of survey readiness. Develops ongoing education and monitoring of all departments in support of regulatory compliance. Attends appropriate meetings for dissemination of information and consultative input. Serves as assigned on quality committees and participates, chairs and oversees performance improvement activities within the accreditation and regulatory arenas. Assists the department administration in managing system accreditation and survey activities.

Essential Functions and Responsibilities:

• Provides direction and oversight for regulatory and accreditation compliance including all local, state, and federal agencies.
• Develops systems to ensure continual organizational readiness.
• Functions as a resource and educator to support management, medical and hospital staff on accreditation and other applicable regulatory requirements to the assigned facility.
• Oversees, within scope of accountability, the regulatory agencies database and inputs data for the application process and monitors the data input for citation clearance. Collaborates with applicable reimbursement team members to ensure regulatory and cost reports/filings are consistent.
• Participates and/or coordinates in unannounced regulatory agency surveys including mock surveys. Designs, implements and takes leadership as directed of the command center during any survey activity.
• Routinely monitors corrective measures to ensure ongoing compliance.