Regulatory/Accreditation Consultant

Job Description

Description

PeaceHealth is seeking a Regulatory/Accreditation Consultant 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.

JOB SUMMARY

Serves as lead to coordinate and facilitate accreditation and regulatory work for hospitals within assigned networks. Leads accreditation regulatory program with assigned scope of responsibility to include, but not limited to; identifies gaps in compliance with state hospital licensing and accreditation standards, communicating to leadership on high risk compliance issues, and supports 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 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.

ESSENTIAL FUNCTIONS

• Works with accreditation and regulatory department to ensure consistent interpretation of regulations.
• Leads the regulatory survey readiness program planning to support PeaceHealth’s mission and values as related to regulatory compliance
• Serves as the liaison between assigned accreditation/regulatory bodies and the hospital.
• 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. Creates tools for manager to utilize to maintain compliance in their designated units.
• 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
• Coordinates post survey activities, which include creation and continued monitoring of corrective action plan activity. Provides expertise and leadership in the development and implementation of action plans including measurement support. Serves as coach or trainer to make sure assigned caregivers know responsibilities and expectations. Ensures executive support and process owners’ engagement in post-survey needs.
• Maintains required reports and summaries of noncompliant issues and survey activity in appropriate databases and update as needed. Utilizes information to prioritize and provide regulatory reports to facilities as scheduled.
• Directs on-site accreditation survey support. Facilitates review and training of survey 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 for leaders and caregivers. Facilitates 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.
• Serves as a consultation resource and is available by phone/email for accreditation/CoP questions, research on state regulations, consult on approaches to compliance, etc.
• Performs other duties as assigned

QUALIFICATIONS Required unless otherwise stated

EDUCATION:

• Bachelor’s degree in health-related field required or equivalent knowledge and skills obtained through a combination of education, training and experiences. RN or other clinical background preferred.

EXPERIENCE/TRAINING:

• Minimum 5 years’ experience in a healthcare discipline, regulatory, patient care, quality or risk.
• Knowledge of state, federal, and accreditation requirements including but not limited to: CMS Conditions of Participation for acute care and critical access hospitals, Accreditation standards and other regulatory areas such as FDA and OSHA.
• Proven skills in team facilitation, project implementation, effective data interpretation, customer relations

LICENSE/CERTIFICATION

• RN preferred
• Valid Driver’s License

OTHER SKILLS:

• 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

PHYSICAL/COGNITIVE REQUIREMENTS:

• 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).

See how PeaceHealth is committed to Inclusivity, Respect for Diversity and Cultural Humility.  

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.