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Position Summary: The Accreditation & Regulatory Affairs Manager ensures continuous regulatory compliance for the assigned licensed/accredited facilities/hospital by CMS and other accreditation agencies by providing consultation and assistance in the development, implementation and measurement of complex cross-functional performance assessment and improvement projects/initiatives to assure accreditation participation requirements are met. The incumbent conducts ongoing performance analysis to identify clinical outcome and other improvement opportunities, coaches/educates providers and management and supports teams/task forces to insure successful outcomes of projects. The Accreditation & Regulatory Affairs Manager works collaboratively with the Director Quality Outcomes & Metrics to share licensed facility and appropriate business unit results related to quality outcomes and metrics within the scope of their role. The incumbent assists with policy review and approval at the licensed facility level while collaborating with the System Policy Specialist to ensure policies across the organization are aligned with best practices and regulatory standards. This Accreditation & Regulatory Affairs Manager builds and maintains strong business relationships with leadership, agency personnel, providers, and employees system-wide to facilitate the overall accreditation and regulatory compliance strategies.
Minimum Requirements: Three (3) years clinical experience in an acute care setting required Five (5) years experience working in a quality management or accreditation support function in a healthcare setting required Consideration may be given to internal candidates not meeting the minimum qualifications
Education/Licenses/Certifications: Bachelors degree in health care field required - Additional experience (10 years or more) in lieu of degree will be considered. Masters degree in health care field preferred Licensed Registered Nurse in the State of Washington preferred Certification in related subject preferred