Director Accreditation and Regulatory Compliance

The Director Accreditation and Regulatory Compliance is responsible for planning implementing reporting and evaluating all aspects of the health system accreditation and regulatory programs and for ensuring that these programs meet the criteria established by the hospital regulatory oversight agencies state and federal mandates and thirdparty payor requirements. The Accreditation and Regulatory Compliance Director provides leadership and management for supervised staff and serves as liaison between hospital departments health system and medical staff administration and outside agencies for accreditation and regulatory issues. The Director works with the Medical Director of Accreditation and Regulatory Compliance.

Essential Functions:

• Assesses plans oversees reports and evaluates all aspects of compliance and accreditation requirements for the Centers for Medicare and Medicaid (CMS) The Joint Commission (TJC) Ohio Department of Health (ODH) and Ohio Department of Mental Health and Addiction Services (OMHAS) for the entire health care system.
• Oversees Regulatory/Accreditation activities: gap analysis and evaluation of key indicators organizational goals cost/benefit analyses information systems implementations facilities design policy revision and correlating documentation forms accreditation compliance works with staff to produce report card and benchmark comparatives provides correspondence and reports to leadership and managed care providers.
• Stays current in knowledge base of existing & new regulatory and accreditation standards for all health system programs.
• Collaborates with committees and staff to ensure comprehensive communication related to accreditation and regulatory standards throughout the health system.
• Designs and oversees audits to track performance and trends and implements strategies to ensure health systemwide compliance with regulatory and accreditation standards.
• Participates in local regional and national organizations focusing on accreditation and regulatory compliance.
• Oversees the health system complaint/grievance system assuring compliance to regulatory expectations. Responsible for ensuring periodic OPPE/FPPE data/reports are provided for medical staff credentialing.
• Supervises staff of the accreditation/regulatory team including staff growth/development and performance evaluations.
• Participates in planning operational oversight and improvement initiatives for the Surgical Verification (CSV) program and supervises the staff responsible for this program.
• Participates in planning operational oversight and improvement initiatives for the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) and supervises the staff responsible for this program.
• Develops recommends and administers department operating and capital budgets.

Education Requirement:

Masters degree in healthcare related discipline or work experience in the field equivalent to a masters degree required.

Licensure Requirement:

(not specified)

Certifications:

CPHQ or CJCP

Skills:

• Strong verbal and written communication skills.
• Strong analytical and organizational skills required to evaluate existing processes and recommend modifications.
• Strong leadership and managerial skills required to mentor and supervise staff.

Experience:

• At least five 5 years experience in hospital based or health system accreditation/regulatory work.
• At least three 3 years experience managing/leading a department or large team.

Physical Requirements:

OCCASIONALLY 133 OF THE TIME 0.5 TO 2.5 HOURS)

Bend/twist

Squat/kneel

Climb stairs/ladders

Standing

Walking

Flexing/extending of neck

Reaching above shoulder

Hand use: grasping gripping turning

Driving motor vehicles (work required)

Lifting/carrying up to 10 lbs.

Pushing/pulling up to 25 lbs.

FREQUENTLY 3466 OF THE TIME 2.6 TO 5.0 HOURS)

Repetitive hand/arm use

Computer skills

CONTINUOUSLY 67 100 OF THE TIME 5.1 TO 12 HOURS OR GREATER)

Sitting

Audible speech

Hearing acuity

Problem solving skills

Decision making skills

Interpreting data skills

Additional Physical Requirements performed but not listed above:

(not specified)

The above list of duties is intended to describe the general nature and level of work performed by individuals assigned to this classification. It is not to be construed as an exhaustive list of duties performed by the individuals so classified nor is it intended to limit or modify the right of any supervisor to assign direct and control the work of employees under their supervision. EOE M/F/Disability/Vet