PeaceHealth is seeking a Regulatory and Accreditation Specialist for a Full Time, 1.00 FTE, Day position.
Must be fully vaccinated for COVID-19 including 2 doses of a 2-dose series or 1 dose of a 1-dose series plus 14 days beyond the final dose prior to start date.
Supports coordination and facilitation of accreditation and regulatory work for hospitals within assigned networks. Accountable for accreditation regulatory program with assigned scope of responsibility to include, but not limited to identifying gaps in compliance with state hospital licensing and accreditation standards, communicating to leadership on high-risk compliance issues, and supporting the development of local leaders and staff to be aware of rules pertaining to their areas of responsibility relating to regulatory compliance. Works with other disciplines and regulatory departments to coordinate compliance efforts across the PeaceHealth system. Serves the organization to promote operational standardization by maintaining one interpretation throughout PeaceHealth as it applies to rules and regulations monitored by this department.
- Supports regulatory survey readiness program planning to support PeaceHealth’s mission, vision and values as related to regulatory compliance.
- Works with regulatory team, local leadership, stakeholders, and subject matter experts to provide oversight to ongoing regulatory readiness within the networks Conducts tracers, internal audits and rounding activities to identify vulnerabilities and to validate compliance with accreditation and regulatory standards. Communicates information and report(s) to appropriate managers, committee, and leadership.
- Proactively addresses accreditation and regulatory compliance issues; works with other departments/system staff to assign ownership and works to correct identified issues prior to external regulatory review.
- Supports post survey activities, which include creation and continued monitoring of corrective action plan activity.
- Maintains required reports and summaries of noncompliant issues and survey activity in appropriate databases and updates as needed. Utilizes information to prioritize and provide regulatory reports to facilities as scheduled.
- Provides on-site accreditation survey support. Works with system and local regulatory team to assure the Survey Command Center is always ready to support survey processes. Serves a key support in the Command Center during survey. Assists in education and training of local leaders regarding command center functions. Documents and processes with facility management and leaders. Reviews survey materials at least quarterly and education at least biannually to ensure strong coordination and staff knowledge of role during external surveys.
- Assists with the development and implementation of regulatory education and core educational materials for leaders and caregivers. Provides local regulatory expertise to promote operational compliance using standard tools and approaches, consistent interpretation of rules and regulations, standardization of process/practice, and outcomes management.
- Participates and assists with the creation of standard work processes pertaining to department; educates and orients local leaders to standard work processes.
- Participates on system and/or local teams charged with regulatory improvement work as needed.
- Performs other duties as assigned.
QUALIFICATIONS Required unless otherwise stated
- Associate degree or equivalent knowledge and skills obtained through a combination of education, training and experiences.
- Bachelor’s degree in a health-related field preferred.
- Minimum 3 year’s Clinical experience required.
- Regulatory, quality or risk experience preferred.
- Excellent verbal and written communication skills.
- Excellent organizational skills.
- Excellent interpersonal skills.
- Ability to make independent judgment and pay close attention to details.
- Ability to maintain confidentiality of highly sensitive information.
- Ability to prioritize and manage multiple projects
- Work requires fairly light physical exertion from up to 65% of the time.
- Ability to lift objects weighing 30 lbs. or less.
- Work is performed under normal working conditions with adequate lighting and ventilation.
- Job duties frequently require intense concentration and attention to detail (up to 65% of work time).
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For full consideration of your skills and abilities, please attach a current resume with your application. EEO Affirmative Action Employer/Vets/Disabled in accordance with applicable local, state, or federal laws.