RN Accreditation and Regulatory Manager
Company: WPA Staffing Solutions, LLC
Location: Palm Springs
Posted on: October 10, 2018
RN Accreditation and Regulatory Manager A Patient Care Company - Palm Springs, CA Full Time Days Description Industry: Healthcare / Health Services Job Category: Medical / Health - Nurse GENERAL DUTIES: Reporting to the Director, Clinical Quality Improvement, the Accreditation and Regulatory Manager plans, organizes, and coordinates all aspects of the hospital Accreditation Program, ensuring that all hospital departments and services on the State of California license are in a continual state of readiness for the Joint Commission (TJC), Centers for Medicaid and Medicare Services (CMS), and California Department of Public Health (CDPH) surveys. Provides oversight for the ORYX and CMS Core Measures process. DEPARTMENT SPECIFIC DUTIES: Implements a multidisciplinary approach to continued survey readiness that includes a steering committee and other committees as necessary. Utilizes tracer methodology as needed. Leads the continued survey readiness program to include the development of detailed action plans, setting deadlines, assigning responsibilities and monitoring progress. Implements a systematic approach to ensure a high level of awareness of regulatory and accrediting agency requirements throughout the hospital including ramifications of failures in compliance. Serves as an expert resource on regulatory/accreditation and licensure standards and expectations for compliance. Provides consultation to leaders and staff involved with the disease specific certification programs. Maintains a timeline for hospital accreditation and disease specific certification programs and provides reminders of required activities to hospital directors. Reviews references materials and communications to stay current with changes in guidelines, standards, goals, trends, survey and training methods. Keeps leadership informed about regulatory changes, oversees incorporation into hospital practice and ensures successful implementation of changes. Identifies areas of vulnerability and assists leaders in developing corrective action plans. Provides education to hospital staff, management and leadership on regulatory items, such as CMS Conditions of Participation (COPs) and National Patient Safety Goals (NPSG). Advises management of the need to add, update and/or modify policies and procedures to meet regulatory requirements. Reviews/revises/proposes policies to ensure compliance with guidelines and regulations. Serves as the liaison to regulatory agencies and accreditation bodies. Manages all agency site visits including scheduling, logistics, and communication to those involved. With unannounced visits, using guest relations skills, determines reason for visit, facilitates retrieval of information and discussion with the most appropriate hospital staff and management. Communicates regularly with Corporate offices to review results of surveys, interpret regulations, and understand trends. Provides consultation to all departments and the medical staff on the interpretation and application of Accreditation standards, and DHS regulations, such as Title 22. Reviews survey results with appropriate management and assists DCQI in development of action plans for compliance. Through task forces, prepares Joint Commission evidence of standards compliance and measure of success data. Assists DCQI in preparation for, responding to, and the management of corporate clinical audits and the Joint Commission PPR. Participates in the annual Failure Mode Effects Analysis with the Risk Manager, CNO, and the DCQI. Follows critical analysis and identification of failure mode (process variation) methodology. Provides oversight of the core measure abstraction process through the outsourced corporate abstractors. Establishes communication regarding new measures, changes in measures, and measure failures. Coordinates the Core Measure Committee to share details on measure failures and provides education Provides education to hospital and medical staff regarding core measure compliance, new measures, and how to comply with the measures. Leads core measure meeting with clinical leaders to address measure failures, provide education specification requirements, and to improve compliance. Qualifications: Required: Current CA RN license with a minimum of 8 years of experience in acute hospital setting. Bachelors degree required, preferably in a health-related field. Experience in facilitating regulatory surveys and surveyor visits for Joint Commission, California Department of Public Health, and Centers for Medicare and Medicaid. Experience in providing education, team facilitation and coaching. Excellent interpersonal, communication skills and presentation skills. Proficiency in Microsoft Office. Preferred: Experience in an acute hospital quality department. Certified Professional in Health Care Quality (CPHQ). Knowledge of Joint Commission Accreditation standards and Conditions of Participation. Compensation Full-time Benefits - Full Relocation Assistance Available - Possible for ideal candidate Candidate Details 5+ to 7 years experience Management Experience Required - No Minimum Education - Bachelor's Degree Willingness to Travel - Never
Keywords: WPA Staffing Solutions, LLC, Palm Springs , RN Accreditation and Regulatory Manager, Healthcare , Palm Springs, California
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