Accreditation Manager Jobs in Santa Rosa, CA (NOW HIRING)

Education and Work Experience:

• Bachelor's Degree or equivalent combination of education/related experience: Required
• Master's Degree: Preferred
• Five years' healthcare or related experience: Preferred
• Three years' in accreditation, regulatory compliance or process improvements: Preferred
• Two years' leadership experience: Preferred

Licenses/Certifications:

• Healthcare Accreditation Certificated Professional (HACP) or Certified Professional in Healthcare Quality (CPHQ) certification: Required within 2 years of hire date

Essential Functions:

• Partners with system, network, and site leadership to align regulatory compliance programs with organizational strategy, quality initiatives, patient safety priorities, and risk reduction goals. Partners with clinical and non-clinical staff to develop, implement, monitor and improve structures required to achieve high quality, safe, cost-effective health care. Assists managers and leaders to mobilize various teams throughout the organization to ensure continuous accreditation standards compliance. Coordinates contract renewal and oversight activities associated with regulatory compliance monitoring system.
• Provides leadership and expertise in the pursuit and attainment of organizational goals related to accreditation, licensing and regulatory compliance. Manages a team of professionals who collectively safeguard facility licensing status, maintain accreditations/certifications, and assure compliance with a vast range of healthcare regulations.
• Conducts annual State regulatory compliance assessment. Develops and maintains any action plan and response to citations for any regulatory agency. Collects data and prepares graphic presentation, and compiles reports to demonstrate compliance. Reviews, interprets and assists hospital departments, leadership and Medical Staff in the implementation of Federal, State and Joint Commission standards and regulations.
• Designs and implement systems to ensure a state of continual regulatory, licensure and accreditation compliance. Supports the accreditation preparation process for the organization by managing logistics, conducting mock surveys and maintaining organization's communication regarding changes and updates for regulatory compliance. Maintains and controls all regulatory, licensure and accreditation documents. Monitors Joint Commission standards compliance. Conducts periodic internal reviews and/or audits to ensure compliance procedures are followed. Identifies compliance issues that require follow-up or investigation. Manages the internal investigations of compliance issues. Reviews operational risks and develops risk management strategies
• Prepares and submits reports following the review of unusual occurrences and adverse events. Alerts appropriate regulatory bodies as required in partnership with network director. Reviews unusual occurrences and adverse events, ensuring that immediate corrective actions are implemented for all reportable events to safeguard patient safety and regulatory compliance. Maintains accurate documentation and reporting systems to support timely submission of required reports and regulatory filings, in alignment with organizational and regulatory standards. Participates in root cause analysis, apparent cause analysis as needed. Collaborates with Risk Management, Quality, Medical staff and other hospital departments as needed in matters related to regulatory compliance, policy planning, and implementation.
• Performs other job-related duties as assigned.

Organizational Requirements:

Adventist Health is committed to the safety and wellbeing of our associates and patients. Therefore, we require that all associates receive all required vaccinations as a condition of employment and annually thereafter, where applicable. Medical and religious exemptions may apply.
Adventist Health participates in E-Verify. Visit https://adventisthealth.org/careers/everify/ for more information about E-Verify. By choosing to apply, you acknowledge that you have accessed and read the E-Verify Participation and Right to Work notices and understand the contents therein.