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Memorial Care

Mgr, Accreditation & Regulatory Compliance

Memorial Care, Long Beach, California, us, 90899


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. 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.

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.

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