Job Details

Summary

SUMMARY: Plans, coordinates, and monitors compliance with federal, state, and local regulations; manages accreditation activities necessary for maintaining required accreditation; manages requirements for certifications and licensure from organizations such as the Joint Commission (JC), California Department of Public Health (CDPH), CMS, OSHPD, CDPH Lab Field Services, and CDPH Radiologic Health Branch. Prioritizes projects, coordinates action plans, and monitors/analyzes results for accreditation projects aligned with the organization's strategic goals.

DUTIES & ESSENTIAL JOB FUNCTIONS: NOTE: Employees in this classification perform these duties but may also perform other related tasks at an equivalent level. Not all duties listed are necessarily performed by each individual.

1. Coordinate the organization's readiness rounds program; develop, communicate, implement, and track action plans to address gaps in care or compliance with TJC standards, CMS, and Title 22 regulations.
2. Assist in accreditation and regulatory activities, including survey preparations and readiness assessments.
3. Develop comprehensive accreditation work plans with clear deliverables, responsibilities, and timelines.
4. Finalize corrective action responses for surveys and investigations from TJC and other agencies.
5. Identify opportunities for growth and improvement in Regulatory Affairs and AHS initiatives.
6. Assess regulatory vulnerabilities and determine escalation levels when necessary.
7. Maintain and implement unannounced survey plans for the department.
8. Manage communications, agendas, and logistics for onsite survey activities.
9. Oversee onsite accreditation and regulatory surveys and support command center activities.
10. Perform additional duties as assigned.
11. Provide guidance on interpreting Joint Commission standards and other regulatory requirements as they relate to organizational practices and performance.
12. Serve as the main contact for accreditation manuals, standards publications, newsletters, and educational materials; disseminate relevant information.

MINIMUM QUALIFICATIONS:
Any combination of education and experience that provides the necessary knowledge, skills, abilities, and required licenses or certifications.

Preferred Education: Master's degree in a healthcare-related field.

Preferred Licenses/Certifications: Certified Professional Healthcare Quality (CPHQ), Certified Joint Commission Professional (CJCP), LEAN/Six Sigma Certification.

Required Education: Bachelor's degree in nursing or a healthcare-related field.

Required Experience: Five years of hospital operations or patient care experience; two years in accreditation, licensing, regulatory compliance, quality, performance improvement, or patient safety in healthcare; experience with quality assurance/performance improvement (QAPI), customer service approaches, and familiarity with Midas, Epic/EHR, County Health Systems, and OSHPD.