REGULATORY COORDINATOR - CONTINUAL ACCREDITATION

REGULATORY COORDINATOR - CONTINUAL ACCREDITATION 

Job Description

Under general direction of the Vice President of Accreditation & Regulatory Readiness, in collaboration with hospital leadership, and according to established policies and procedures, coordinates and provides leadership in the hospital (in and outpatient services) accreditation and regulatory readiness surveys, activities and improvements, to achieve and sustain compliance with internal and external standards/regulations principles of medical and patient safety.  

Collaborates to identify accreditation/regulatory compliance improvement opportunities/priorities, develop accreditation/regulatory readiness plans and follow through on implementation of plans to ensure accreditation and regulatory requirements are met.  

Collaborates with system accreditation/regulatory and hospital leadership to ensure audits and action plans, recommendations for improvement and updates are provided to regulatory governing bodies as deemed.  

Provides leadership and education and serves as a resource to departments regarding compliance with accreditation/regulatory standards/regulations, process/performance measurements, monitoring and evaluation. 

Provides facility, system and program support during accreditation and regulatory events. Defines and obtains necessary reports and metrics reflecting stability as relates to accreditation and regulatory compliance.  

Maintains current knowledge of accreditation and regulatory requirements and develops appropriate implementation plans for new requirements.  

Develops, monitors and revises functional processes in accordance with goals and objectives. Provides input into the development and revision of organizational structure for area. Develops current to intermediate goals and measures for the department. Measures and assesses performance. As requested, assists in long-range goals development. Develops and monitors budget for areas of responsibility.

Remains current on accreditation and regulatory standards/regulations.

Leads site Accreditation/Regulatory Readiness Committee.

Monitors activities for and ensures compliance with laws and government regulations. Responsible for DMC policies, as well as JC (Joint Commission, State and Federal agencies) cooperation and follow-up. As directed, implements external and internal audit recommendations.  

Other duties as assigned.

Minimum Qualifications

1. Bachelor’s degree in Health Care Administration, Operations Analysis, clinical or other related field, or the equivalent combination of education and/or experience. Master’s degree preferred.

2. Licensed to practice as a Registered Nurse in the State of Michigan, or licensed to practice in other health-related field.

3. Three to five years progressively more responsible experience in leading hospital accreditation.

4. Three years progressively more responsible leadership experience in an acute care facility with at least one year of frequent involvement with senior management, physicians and outside patient care providers.

5. Experience in the use of personal computers as well as knowledge of statistical or spreadsheet software tools.

CANDIDATE DETAILS

2+ to 5 years experience

Minimum Education - Bachelor's Degree

SCREENING QUESTIONS

Does the candidate have at least an Associate’s degree in Nursing?

Does the candidate have at least 3 years of experience leading hospital accreditation?

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