looking for Manager of Accreditation, Regulatory & Licensing at Los Angeles, CA Full Time

NOW HIRING! Full-time, direct-hire Manager- Accreditation Licensing for a top facility in LA County. Competitive compensation and enticing benefits.

Pay: $86,355 – $128,381/year

Job Summary:

Responsible for leadership, management, and services for accreditation, regulatory, and licensing for state and federal regulatory readiness. Responsibilities include organizing, planning, directing, and evaluating ongoing readiness and regulatory efforts for inpatient and outpatient services. Must communicate, guide and assist all departments with regulatory compliance.

• Demonstrates compliance with Code of Conduct and compliance policies, and takes action to resolve compliance questions or concerns and report suspected violations
• Must demonstrate and maintain knowledge of regulatory and accrediting agencies’ standards related to both hospital and physicians’ services, including comprehensive knowledge of Joint Commission Accreditation procedures and regulations
• Oversees Program Development
• Manages and directs the implementation of JC’s Hospital Accreditation Standards program
• Chairs the monthly Continuous Survey Readiness Committee meetings
• Champion and manage the requirements for certifications and licensure for a variety of organizations, such as Joint Commission (JC), California Department of Public Health (CDPH), CMS, OSHPD, other CDPH branches.
• Directs the planning, development, and implementation of hospital corrective action plans
• Manages compliance with JC and other accrediting organizations, including CMS and the Department of Public Health
• Cultivates and manages hospital relationships with accreditation organizations
• Oversees compliance with the Ethics, Rights, and Responsibilities standards for The Joint Commission
• Administers and facilitates debriefing for all survey preparedness/continuous safety rounding, and completion and submission of the Leapfrog Survey
• Demonstrates success in collaborating with key leaders, in order to define processes and projects to achieve identified goals within specified timelines
• Achieves continuous survey readiness across the organization
• Demonstrates ability to integrate and interpret data from diverse sources addressing issues of high complexity
• Identifies regulatory vulnerabilities and determines escalation level if necessary
• Provides guidance on Joint Commission standards interpretation and other regulatory requirements as they apply to organizational practice/performance
• Actively coordinates the organization’s readiness rounds program and is primarily responsible for the development, communication, implementation and tracking of action plans necessary to close identified gaps in care of compliance with The Joint Commission (TJC) standards and Centers for Medicare and Medicaid Services (CMS) and Title 22 regulations
• Assists in all accreditation and regulatory activities, including surveys, survey preparation and readiness assessments.
• Develops comprehensive accreditation work plans by establishing deliverables, accountabilities, and timelines
• Serves as the contact and point person for Joint Commission accreditation manuals, standards-related publications and newsletters and educational materials; distributes pertinent information
• Maintains and implements department unannounced survey plans
• Manages onsite accreditation and regulatory surveys; supports command center activities
• Manages communications, agendas, and logistics for onsite survey activities
• Finalizes corrective action responses to The Joint Commission and other regulatory agencies for survey and for-cause and complaint investigations
• Prepares the Joint Commission applications or accreditation, updates information accurately
• Performs other duties as assigned.

Job Qualifications:

Minimum Education

• Bachelor’s degree from an accredited four-year college or university

Preferred Education

• Master’s degree from an accredited four-year college or university

Minimum Work Experience and Qualifications

• 3+ years of recent regulatory experience in an acute health care organization
• Joint Commission and Leapfrog survey experience
• Accreditation activities and survey preparation
• Knowledge of CMS, Title 22, Joint Commission, and Cal OSHA law and regulations

Preferred Work Experience and Qualifications

• 1-3 years Supervisory experience
• Leadership skills.
• Ability to manage multiple projects with competing priorities.

Required Licensure, Certification, Registration or Designation

• Current Los Angeles County Fire Card required (within 30 days of employment).

Email your resume to [email protected] ASAP or apply here for consideration.

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