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Manager - Regulatory Accreditation, Licensing and Certification

Company: Evergreen Healthcare
Location: Kirkland
Posted on: June 8, 2021

Job Description:

Job Summary:

Responsible for the coordination of a broad range of activities that sustain ongoing awareness of and compliance with organization-wide regulatory compliance requirements, including Joint Commission and Department of Health (DOH) standards, including all associated follow up reporting.

Primary Duties:

  1. Works collaboratively with all levels of staff within the organization, including senior leadership, medical staff leadership, nursing and support staff to build a strong knowledge of and compliance with regulatory standards/requirements across the organization.

  2. Leads and coordinates preparation for Joint Commission and other accreditation, certification and regulatory reviews; manages the survey processes including survey schedule, surveyor support and required follow up.

  3. Provides the organization wide coordination of regulatory compliance and survey readiness for all services within Evergreen including EMG, Home Care, Hospice and specialty clinics.

  4. Responsible for investigating, follow up and appropriate notification of significant adverse/reportable events.

  5. Performs other duties as assigned.

REQUIRED for the position:

  • Bachelor's degree in Nursing or a related field
  • 5 years of related clinical experience
  • Knowledge of Joint Commission Standards, Survey process or related requirements
  • Knowledge of methods of data collection, manipulation, interpretation, and presentation of information
  • Demonstrated ability to lead multidisciplinary organization-wide teams
  • Knowledge of health care trends, care processes, and best practices that support regulatory requirements
  • Experience with the Tracer Methodology
  • Demonstrated ability to establish cooperative working relationships with diverse groups and individuals, medical staff, and other health care disciplines
  • Knowledge of and demonstrated experience with improvement techniques (methods), including root cause analysis, cause and effect analysis, and failure mode and effects analysis as applied to the health care setting
  • Skills with information management systems to support regulatory compliance, including database management, database analysis and reporting, and flowchart software
  • Requires skill to plan, organize, and direct teams and to negotiate effectively with management to accept and implement recommendations, where proposals involve substantial organizational resources, require extensive changes in established procedures, or may be in conflict with the proposed requirements
  • Knowledge in and the ability to apply the principles of project management and change management
  • Demonstrated organization, facilitation, communication, and presentation skills
  • Computer skills including the use of Microsoft products in a Windows environment, as well as spreadsheets and QI data display software
  • Familiarity with clinical documentation; i.e. patient chart
  • Previous leadership responsibility in healthcare setting

DESIRED for the position:

  • Master's degree


Keywords: Evergreen Healthcare, Kirkland , Manager - Regulatory Accreditation, Licensing and Certification, Other , Kirkland, Washington

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