Mgr, Accreditation & Regulatory Compliance

Title: Mgr, Accr & Reg Compliance

Location: Long Beach, CA

Department: Quality Assurance

Status: Full-time

Shift: Days

Pay Range*: $60.81/hr - $91.21/hr

At MemorialCare Health System, we believe in providing extraordinary healthcare to our communities and an exceptional working environment for our employees. MemorialCare stands for excellence in healthcare. Across our family of medical centers, we support each one of our bright, talented employees in reaching the highest levels of professional development, contribution, collaboration and accountability. Whatever your role and whatever expertise you bring, we are dedicated to helping you achieve your full potential in an environment of respect, innovation and teamwork.

Position Summary

This position requires the full understanding and active participation in fulfilling the mission of MemorialCare Long Beach Medical Center. It is expected that the employee demonstrate behavior consistent with our core values: Integrity, Accountability, Best Practices, Compassion and Synergy. The employee shall support Long Beach Medical Center’s strategic plan and participate in and advocate performance improvement/patient safety activities.

Works collaboratively with the Director & Vice President (VP) Quality & Patient Safety to oversee all regulatory and accreditation activities for MemorialCare Long Beach Medical Center (LBMC) & Miller Children’s & Women’s Hospital Long Beach (MCWH). Provides leadership for quality and hospital staff in the development, implementation, measurement and monitoring of regulatory and accreditation compliance while ensuring alignment with strategic initiatives. Ensures compliance with regulatory standards defined by governing bodies, such as The Joint Commission, Title 22, Centers for Medicare & Medicaid Services (CMS) Conditions of Participation, California Children’s Services (CCS). Provides continuous evaluation of the hospital’s compliance with all local, Federal, and State laws and regulations, as well as accreditation standards. Assesses and recommends process changes to support a strong regulatory compliance program. Works together with the Quality & Patient Safety leadership to ensure the facility maintains good standing through meeting the mandated regulatory and accreditation standards and requirements.

Oversees the regulatory, accreditation, and licensing preparation process by managing logistics, conducting mock surveys, providing education, and maintaining the hospital's communication regarding changes and updates. In collaboration with the Director of Quality, Patient Safety & Accreditation, will be the liaison for onsite surveys, develop plans for sustaining improvements and ensure ongoing compliance. Serves as an expert resource in regulatory, accreditation, and licensure standards. Serves as a liaison to leadership, staff, and physicians for performance improvement activities for both regulatory as well as other quality initiatives as assigned.

Principal Duties and Responsibilities:

·In collaboration with the Director & VP, coordinate regulatory, accreditation, and licensure activities including but not limited to, actual and mock survey activity, unit tracers, staff and physician education, and responses to findings (plans of correction) and inquiries.

·Manages improvement processes and programs related to all accreditation and licensing activities, ensuring sustained compliance with submitted plans of correction.

·Provides direction and support, through collaboration with leadership and staff, for activities related to accreditation, licensure, regulatory affairs, and performance improvement.

·Demonstrates an understanding of quality, safety, service, and regulatory standards from external agencies including, but not limited to, The Joint Commission, Centers for Medicare and Medicaid Services (CMS), and California Department of Public Health.

·Provides consultation to relevant task forces, quality teams, committees, and policy and procedure committee to ensure consistency and compliance to regulatory and accreditation requirements.

·Communicates requirements and standards in a timely manner to the leadership and staff. Translates standards, requirements and policies into terms or processes meaningful to the targeted audiences.

·Provides education for the organization on regulatory, licensing and accreditation issues.

·Coordinates contract review and oversight activities with identified leaders.

·Reviews hospital policies for internal consistency and compliance to regulatory and accreditation requirements.

·Demonstrates knowledge in performance improvement methodologies to promote patient safety and regulatory compliance. 

·Supports an environment for innovation and success of the infection prevention program as defined by Infection Prevention strategic initiatives while ensuring alignment with regulatory requirements.

·Performs other duties as assigned.

Placement in the pay range is based on multiple factors including, but not limited to, relevant years of experience and qualifications. In addition to base pay, there may be additional compensation available for this role, including but not limited to, shift differentials, extra shift incentives, and bonus opportunities. Health and wellness is our passion at MemorialCare—that includes taking good care of employees and their dependents. We offer high quality health insurance plan options, so you can select the best choice for your family. And there’s more...Check out our MemorialCare Benefits for more information about our Benefits and Rewards.

Minimum Requirements

·       Bachelor’s degree in work-related field/discipline (ie: Nursing, Pharmacist, Physical Therapist) required.

·       Master’s degree in nursing, health management or related discipline preferred.

·       Current California RN Licensure and/or Certification in a Healthcare field preferred (ie: RN, PT, RT, Pharmacist).

·       Current regulatory/quality certification Healthcare Accreditation Certification Program (HACP), Certified Professional in Healthcare Quality (CPHQ), Certified Joint Commission Professional (CJCP), or Institute of Healthcare Improvement (IHI) preferred.

·       Six Sigma, Lean, or other improvement certification preferred.

·       Minimum 2 years’ accreditation or healthcare regulatory compliance experience and/or equivalent required.

·       Experience in an acute care setting required.

·       Previous experience in quality review, analysis, and reporting preferred.

·       Working knowledge of state, federal, and national accreditation standards in a hospital or healthcare related field (ie: The Joint Commission, Centers for Medicare and Medicaid Services (CMS), Title 22, etc.) Key characteristics of the incumbent include:

·       Ability to inspire, create, and articulate a shared, compelling vision which translates into actionable measures to attain the organization's strategic performance goals.

·        Proven ability to work cross-functionally in team environments to develop, evaluate, and execute best practice initiatives designed to promote excellence across the care continuum.

·       Demonstrated innovative ideas in health care delivery with ability to influence and acquire necessary resources across departments.

·       High emotional quotient with a mature, self-confident demeanor that is effective and credible across all levels of the organization, including senior management and medical staff.

·       High level of proficiency with analytic tools & to display data for action-oriented results

·       Ability to meet constant, competing, and changing deadlines.

·       Proficient in computer skills including Microsoft Office (Word, Excel, PowerPoint, Outlook etc.,) and Electronic Medical Record such as EPIC