Accreditation and Regulatory Program Leader

Accreditation & Regulatory Program Leader

Department: Quality Performance Improvement

Location: Trinity Health Livonia

Total Rewards and Benefits:

• Competitive compensation DAILYPAY

• Benefits effective Day One! No waiting periods.

• Full benefits package including Medical Dental Vision PTO Life Insurance Short and Long-term Disability

• Retirement savings plan with employer match and contributions

• Opportunity for growth and advancement throughout Trinity Health

• Tuition Reimbursement

Position Purpose:

Provides management and expertise in the areas of external regulatory compliance and quality and patient safety standards as it relates to colleagues medical staff and inpatient/outpatient services. Collaborates with local and regional leadership to direct and coordinate the planning implementation and evaluation of clinical process related to regulatory compliance. Leverages clinical information technology process design change management and evidence to ensure ongoing survey readiness and compliance with accreditation regulations and standards.

Shifts Available: Days

Required Qualifications:

Education:

• Bachelors degree in nursing pharmacy or other clinical or health care systems background. Masters degree in healthcare or healthcare-related field and Six Signma training at green belt or higher is preferred.

Experience:

• A minimum of five years clinical experience including at least one to two years in leadership or management. Experience with and understanding of key functions of hospital and medical staff departments or services. Previous accreditation experience with an in-depth understanding of regulatory requirements and healthcare operations is preferred. Certificate as a Joint Commission Professional (CJCP) preferred.

Physical and Mental Requirements and Working Conditions:

• Advanced interpersonal skills necessary to effectively communicate complex theoretical and technical concepts effectively with a wide variety of individuals.

• Advanced analytical and computer skills in order to manage project work and data.

• Advanced critical thinking skills necessary to develop sound recommendations and assist in implementing improved delivery of care systems policies and procedures evaluating clinical practice outcomes and developing educational programs.

• Manages and directs the implementation of organization regulatory compliance activities across all areas partnering with unit and program managers and leaders as appropriate.

• Leads the organization in pre-survey activities.

• Coordinates organizational response during CMS state licensing surveys and Joint Commission surveys.

• Communicates survey results develops action plans and survey responses in accordance with regulatory timelines.

• Manages complaint responses and associated action plans.

• Manages the routine and ongoing function of the accreditation software Joint Communication extranet and monitors the websites to assure compliance with regulatory reporting requirements.

• Utilizes performance improvement methodologies and change management strategies to address identified compliance gaps in regulations and standards.

• Strategizes with various levels of leadership to develop organization response to new regulations and standards with health system leadership.

Our Commitment

Rooted in our Mission and Core Values we honor the dignity of every person and recognize the unique perspectives experiences and talents each colleague brings. By finding common ground and embracing our differences we grow stronger together and deliver more compassionate person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race color religion sex sexual orientation gender identity national origin disability veteran status or any other status protected by federal state or local law.