Mchonline
Accreditation & Regulatory Compliance Manager
Mchonline, California, Missouri, United States, 65018
Accreditation & Regulatory Compliance Manager
8 days ago
Requisition ID: 1832Salary Range: $100,000.00 To $130,000.00 AnnuallyPOSITION SUMMARYUnder the direction of the Chief Nursing Officer or designee, the Accreditation & Regulatory Compliance Manager is responsible for evaluating and monitoring hospital compliance with regulatory requirements and accreditation standards as assigned. This position requires the full understanding and active participation in fulfilling the mission of MCH. The Accreditation & Regulatory Compliance Manager is expected to demonstrate behavior consistent with the MCH’s values and shall support its strategic plan, goals and direction of the hospital survey readiness performance plan.MAJOR RESPONSIBILITIESSERVICE PERFORMANCEGreets/acknowledges customers warmly, with a smile, and immediately when they enter department/unit/area.Asks how the customer may be helped with interest and concern.Listens attentively, does not interrupt.Accepts ownership and takes action to resolve customer needs and/or concerns.Is attentive and responsive to the expectations of physicians, co-workers and direct reports.Accepts constructive criticism and modifies actions accordingly.Is generous in acknowledging a job well done.Uses words and behaviors that express consideration, concern and respect.Facilitates and holds leadership accountable for meeting department customer service standards in the performance of duties.Keeps all private information about staff or patients confidential.Identifies customers and their service requirements.Meets or exceeds customer service improvement targets as demonstrated by dashboards, etc.Engages in interdepartmental/multi-department/house-wide process improvement forums/task forces/committees.Offers and implements solutions to challenges/problems.Attends/participates in activities that contribute to professional growth and development.PRIMARY POSITION RESPONSIBILITIESResponsible for conducting daily and ongoing clinical and system tracer activities to ensure accreditation standards and regulatory requirement compliance.Functions as accreditation and regulatory compliance auditor, conducting internal and focused audits as needed; and serving as facilitator on Corrective Action Teams to resolve non-compliant standards and elements of performance.Collects, trends, reports and displays mock tracer findings using AMP Tracer software.Assist with developing, implementing, maintaining and improving hospital pre-survey activities that foster collaboration among all disciplines involved in the care of all patient populations served.Monitors performance measures for assigned Joint Commission specialty certification programs to ensure compliance and improved program outcomes.Collaborates and effectively communicates with a wide variety of disciplines within the organization to evaluate, improve, and sustain performance improvement initiatives while serving as a resource for those efforts.Responsible for evaluating and reporting hospital-wide accreditation and regulatory survey readiness activities/initiatives including patient satisfaction improvement initiatives.Recommends changes in the administrative policies that conform to accreditation standards and California/Federal regulations.Submits accurate and timely status reports to the Survey Readiness Workgroup and/or hospital committees as directed.Performs other duties as related to position or assigned.QUALIFICATIONSRegistered Nurse License in the State of California preferred.Minimum of three years acute care adult, critical care, or emergency nursing experience preferred.Three years accreditation and survey experience in acute care hospital setting.Knowledge of state and federal regulatory and Joint Commission accreditation requirements as they relate to performance improvement and patient safety preferred.Proficient computer skills and experience using Microsoft Word and Microsoft Office software.Current BCLS Certification.Special Knowledge, Skills, and Abilities RequiredStrong knowledge of process improvement tools and techniques.Strong interpersonal skills and demonstrated ability to work with multidisciplinary groups and teams.Skilled in verbal and written communication.Ability to analyze and solve problems.Ability to work independently and interdependently.Proven time management skills and able to meet deadlines.Work EnvironmentNormal office conditions.Prolonged sitting, standing, or walking may be required during shift.Use of computer, standard office equipment, and hospital survey software.
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8 days ago
Requisition ID: 1832Salary Range: $100,000.00 To $130,000.00 AnnuallyPOSITION SUMMARYUnder the direction of the Chief Nursing Officer or designee, the Accreditation & Regulatory Compliance Manager is responsible for evaluating and monitoring hospital compliance with regulatory requirements and accreditation standards as assigned. This position requires the full understanding and active participation in fulfilling the mission of MCH. The Accreditation & Regulatory Compliance Manager is expected to demonstrate behavior consistent with the MCH’s values and shall support its strategic plan, goals and direction of the hospital survey readiness performance plan.MAJOR RESPONSIBILITIESSERVICE PERFORMANCEGreets/acknowledges customers warmly, with a smile, and immediately when they enter department/unit/area.Asks how the customer may be helped with interest and concern.Listens attentively, does not interrupt.Accepts ownership and takes action to resolve customer needs and/or concerns.Is attentive and responsive to the expectations of physicians, co-workers and direct reports.Accepts constructive criticism and modifies actions accordingly.Is generous in acknowledging a job well done.Uses words and behaviors that express consideration, concern and respect.Facilitates and holds leadership accountable for meeting department customer service standards in the performance of duties.Keeps all private information about staff or patients confidential.Identifies customers and their service requirements.Meets or exceeds customer service improvement targets as demonstrated by dashboards, etc.Engages in interdepartmental/multi-department/house-wide process improvement forums/task forces/committees.Offers and implements solutions to challenges/problems.Attends/participates in activities that contribute to professional growth and development.PRIMARY POSITION RESPONSIBILITIESResponsible for conducting daily and ongoing clinical and system tracer activities to ensure accreditation standards and regulatory requirement compliance.Functions as accreditation and regulatory compliance auditor, conducting internal and focused audits as needed; and serving as facilitator on Corrective Action Teams to resolve non-compliant standards and elements of performance.Collects, trends, reports and displays mock tracer findings using AMP Tracer software.Assist with developing, implementing, maintaining and improving hospital pre-survey activities that foster collaboration among all disciplines involved in the care of all patient populations served.Monitors performance measures for assigned Joint Commission specialty certification programs to ensure compliance and improved program outcomes.Collaborates and effectively communicates with a wide variety of disciplines within the organization to evaluate, improve, and sustain performance improvement initiatives while serving as a resource for those efforts.Responsible for evaluating and reporting hospital-wide accreditation and regulatory survey readiness activities/initiatives including patient satisfaction improvement initiatives.Recommends changes in the administrative policies that conform to accreditation standards and California/Federal regulations.Submits accurate and timely status reports to the Survey Readiness Workgroup and/or hospital committees as directed.Performs other duties as related to position or assigned.QUALIFICATIONSRegistered Nurse License in the State of California preferred.Minimum of three years acute care adult, critical care, or emergency nursing experience preferred.Three years accreditation and survey experience in acute care hospital setting.Knowledge of state and federal regulatory and Joint Commission accreditation requirements as they relate to performance improvement and patient safety preferred.Proficient computer skills and experience using Microsoft Word and Microsoft Office software.Current BCLS Certification.Special Knowledge, Skills, and Abilities RequiredStrong knowledge of process improvement tools and techniques.Strong interpersonal skills and demonstrated ability to work with multidisciplinary groups and teams.Skilled in verbal and written communication.Ability to analyze and solve problems.Ability to work independently and interdependently.Proven time management skills and able to meet deadlines.Work EnvironmentNormal office conditions.Prolonged sitting, standing, or walking may be required during shift.Use of computer, standard office equipment, and hospital survey software.
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