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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 the monitoring and maintaining the Kenaitze Indian Tribe's (the Tribes) policies, procedures, standard work, forms, Charters, Ordinances, and other documents. The Accreditation and Policy Manager ensures that all documents in the system 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 Accreditation and Policy Manager will take a lead role in collaborating with department heads in maintaining continual compliance with Commission on Accreditation of Rehab Facilities (CARF) standards. Responsible for exploring and pursuing other accreditation, as appropriate, to ensure the Tribe maintains the highest possible service delivery standards.

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 that all regulatory required documents remain active in the system and reflect changes imposed by the 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 any findings
• Communicates obstacles to Director of Quality, Compliance & Privacy in a timely manner. Prepares documents for external surveys/reviews, compliance plan 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), the National Association for Healthcare Quality (NAHQ) or any other professional organizations as applicable
• Ensures compliance with Tribal, federal, state, and local employment laws and regulations, Tribal policies and 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 follow or 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 Conditions

Lifting Requirements

Sedentary work - Exerting up to 10 pounds of force occasionally, and/or a negligible amount of force frequently or constantly to lift, carry, push, pull or otherwise move objects, including the human body. Sedentary work involves sitting most of the time. Jobs are sedentary if walking and standing are required only occasionally, and all other sedentary criteria are met.

Physical Requirements

• Stand or Sit (Stationary position)
• Walk (Move, Traverse)
• Use hands/fingers to handle or feel (Operate, Activate, Use, Prepare, Inspect, Place, Detect, Position)
• Stoop, kneel, crouch or crawl (Position self (to), Move)
• Talk/hear (Communicate, Detect, Converse with, Discern, Convey, Express oneself, Exchange information)
• See (Detect, Determine, Perceive, Identify, Recognize, Judge, Observe, Inspect, Estimate, Assess)
• Taste/Smell (Detect, Distinguish, Determine)
• Pushing or Pulling
• Repetitive Motion

OSHA Categories

Category III - Normal routine involves no exposure to blood, body fluid or tissue and as part of their employment, incumbents are not called upon to perform or assist in emergency care or first aid

Equipment and Tools

List Equipment used for job:

List Tools:

Drives KIT or Personal Vehicle:

Travel

• Local
• In-State
• Out-Of-State

Qualifications

Education

• 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 must 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 and procedures to address nursing, medical, and BH provider issues related to policies, procedures, etc.
• Knowledge of Medicaid and National healthcare compliance regulations and practices
• Experience with Survey prep 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

This position is a Covered Position subject to all requirements of the Alaska Barrier Crimes Act (ABCA) and to 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.