Accreditation and Regulatory Compliance Manager
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Job Location:
Saint Paul, MN - USA
Monthly Salary:
Not Disclosed
Posted on:
Yesterday
Vacancies:
1 Vacancy
Job Summary
Regions Hospital is seeking an experienced resilient and adaptable leader to oversee a comprehensive facilitywide regulatory and accreditation program. This role ensures ongoing readiness for Joint Commission and Minnesota Department of Health surveys while maintaining compliance with all applicable state requirements. The position also drives systemwide standardization education and performance improvement by assessing organizational compliance partnering with leaders and guiding interdisciplinary teams toward continuous readiness. Additionally this leader will develop postsurvey response plans manage two team members and report directly to the Director of Quality Patient Safety and Accreditation.
Major job duties include: managing and supporting a systematic approach for Accreditation and Regulatory Compliance and Surveillance designing and maintaining foundation and infrastructure for a robust survey readiness program managing and leading the MDH visits and Joint Commission survey preparedness and Center for Medicare Services surveys and necessary follow up activities providing and coordinating implementation of education training and consultation in relation to identified learning needs as well as participating in various teams and committees to support improvement efforts and readiness.
Work Schedule/FTE:1.0 FTE (40 hours per week) working days (8am-5pm)
This is a hybrid role. It requires that you are primarily on-site at Regions Hospital with work from home 1 day per week.
Required Qualifications:
Education: Bachelors degree in nursing Quality Management Hospital Administration or healthcare related field
Experience:
3-5 years of work experience in a hospital or clinical healthcare setting
Two years of experience in accreditation and/or regulatory compliance
Five years of experience in project management
1-3 years supervisory/management experience
Certification: none
Knowledge Skills and Abilities:
Expert knowledge of The Joint Commissions (TJC) Centers for Medicare and Medicaid Services (CMS) Minnesota Department of Health (MDH)and other related standards and regulations
Familiarity with OSHA Building and Fire codes
PDSA (Plan Do Study Act) experience
Leadership of on-site surveys
Manage the surveillance function for reporting and regulatory and compliance changes
Proficient in interpretation and application of standards with proven success in performing gap assessment and assignment of criticality/risk.
Ability to identify and collaborate with key stakeholders to develop clear action plans and oversee their implementation
Monitor and validate ongoing compliance readiness of the organization
Successfully demonstrated ability to lead large scale projects and utilize performance improvement methods such as Lean or Six Sigma
Ability to effectively communicate with individuals from all disciplines and all levels of the organization
Excellent critical thinking skills
Exceptional capabilities in leading collaborating and influencing teams and individuals to improve performance and compliance
Excellent verbal and written communication skills include the ability to communicate complex information in a clear concise and professional manner.
Demonstrated ability to prepare and present to senior leadership
Highly skilled in analyzing data and presenting data to identify opportunities and drive decisions
Ability to successfully and independently use technology includes ability to create templates tables and tracking tools PowerPoint presentations.
Preferred Qualifications:
Education: Masters in healthcare business
Experience: 5 years of experience in accreditation and/or regulatory
Certification: Green or black belt certification lean or six sigma training CPHQ ASQ or certified join commission professional
Benefits:
Our benefits include medical and dental insurance (which begin on the first day of the month following start) 401k with match disability insurance fertility benefits tuition reimbursement educational reimbursement toward continuing education and we are a qualified non-profit employer under the federalPublic Service Loan Forgiveness program. We offer an onsite employee fitness center and an onsite employee clinic to make it more convenient for our staff to get the care they need. We also have a Center for Employee Resilience that provides support and evidence-based practices to bring relief and build resiliency. Regions is also proud to be aBeyond the Yellow Ribbon Company.
Required Experience:
Manager
Key Skills
- Proofreading
- Adobe Acrobat
- FDA Regulations
- Manufacturing & Controls
- Biotechnology
- Clinical Trials
- Research & Development
- GLP
- cGMP
- Product Development
- Chemistry
- Writing Skills
About Company
At HealthPartners we believe in the power of good – good deeds and good people working together. As part of our team, you’ll find an inclusive environment that encourages new ways of thinking, celebrates differences, and recognizes hard work. We’re a nonprofit, integrated health care ... View more
