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Accreditation and Policy Manager

Department: Quality, Compliance & Privacy

Program: Quality, Compliance & Privacy

Reports To: Director of Quality, Compliance and Privacy

Employment Status: Full Time

FLSA Status: Exempt

Schedule: 40 Hours/Week

Preference: TERO Ordinance 2017-01, P.L. 93-638

Job Summary

The Accreditation and Policy Manager is responsible for monitoring and maintaining the Kenaitze Indian Tribe's policies, procedures, standard work, forms, charters, ordinances, and other documents. The manager ensures all documents are managed by responsible leaders in accordance with Federal, State, and accrediting bodies to maintain certification and licensure. Recommendations for documents will meet or exceed best practice principles, encouraging staff to provide quality and safe care for our patients/clients (un'ina). The manager will take a lead role in collaborating with department heads to maintain continual compliance with the Commission on Accreditation of Rehabilitation Facilities (CARF) standards and will explore and pursue other accreditation opportunities as appropriate.

Essential Functions

• Conducts regular monitoring, development, and training of the policy management system; collaborates with department managers providing education and guidance regarding effective development of documents.
• Ensures all regulatory required documents remain active and reflect changes imposed by regulatory bodies.
• Participates in and/or co‑facilitates workgroup meetings for policy development and accreditation compliance.
• Completes and documents quarterly updates on the Annual Quality Assurance/Performance Improvement (QAPI) work plan.
• Maintains continual accreditation survey readiness by conducting mock surveys and audits, and developing corrective action plans to address findings.
• Communicates obstacles to Director of Quality, Compliance & Privacy in a timely manner; prepares documents for external surveys/reviews, compliance plans, and quality improvement plans.
• Coordinates and delivers staff education.
• Leads policy and accreditation planning sessions with departments as needed.
• Stays current with healthcare regulations and standards.
• Seeks continuing education opportunities with the Institute for Healthcare Improvement (IHI), National Association for Healthcare Quality (NAHQ), or other professional organizations as applicable.
• Ensures compliance with Tribal, federal, state, and local employment laws and regulations, Tribal policies, and the TERO ordinance.

It is the intent of this job description to highlight the essential functions of the position; however, it is not an all‑inclusive list. The incumbent may be called upon and required to perform other duties and tasks requested by his/her supervisor, consistent with the purpose of the position, department, and/or the Kenaitze Indian Tribe's objectives.

Working ConditionsLifting Requirements

Sedentary work: Exerting up to 10 pounds of force occasionally; lifting, carrying, pushing, pulling or otherwise moving objects. Sedentary work involves sitting most of the time; walking and standing occur only occasionally.

Physical Requirements

• Stand or sit in a stationary position.
• Walk to move between locations.
• Use hands/fingers to handle or feel items.
• Sto op, kneel, crouch or crawl as needed.
• Talk and hear for communication.
• See to identify and inspect.
• Taste or smell as required.
• Push or pull objects.
• Perform repetitive motions.

OSHA Categories

Category III – Normal routine involves no exposure to blood, body fluid or tissue, and incumbents are not involved in emergency care or first aid.

Equipment and Tools

List of equipment and tools used for the job: [Not specified].

Travel

• Local
• In‑State
• Out‑of‑State

QualificationsEducation

• Bachelor’s degree in healthcare or related field, or a combination of education and experience may be substituted for a degree.

Experience

• Two (2) years of experience in policy development or policy management in a healthcare setting.
• Two (2) years of experience leading a healthcare system to achieve successful accreditation.

License/Certification

• Must have a valid Alaska State driver’s license and remain insurable under the Tribe’s policy.

Special Skills

• Proven ability to work on several projects simultaneously and under tight schedules.
• Strong interpersonal skills.
• Excellent problem‑solving skills.
• Excellent writing skills with the ability to create business/healthcare documents.
• Strong knowledge of medical terminology to address nursing, medical, and behavioural health provider issues related to policies and procedures.
• Knowledge of Medicaid and national healthcare compliance regulations and practices.
• Experience with survey preparation for accrediting bodies such as CARF, AAAHC, etc.
• Conducts business in a service‑oriented manner that is attentive, pleasant, respectful, and kind when dealing with un’ina, visitors, co‑workers and others.
• Ability to work independently as well as collaboratively.

EEO Statement

This position is a Covered Position subject to all requirements of the Alaska Barrier Crimes Act (ABCA) and the Indian Child Protection and Family Violence Prevention Act (ICPA). ABCA and ICPA requirements apply and must be complied with at all times in order to remain in the position.