Our client, a leading national healthcare services company, is seeking an Accreditation and Regulatory Manager. In this role, you will support the regulatory, accreditation and contractual compliance of the hospital with a focus on Joint Commission Survey readiness.
Primary Responsibilities of an Accreditation and Regulatory Manager – Joint Commission:
- Technical support for regulatory, accreditation and contractual (payer) compliance, including coordination of Joint Commission Survey readiness (application, pre and post survey follow up), reporting of various regulated and organization metrics
- Compile high level Joint Commission readiness reports on a monthly basis for the purpose of senior level reporting.
- Review policy and procedures to assure regulatory compliance.
- Coordinate accreditation committee, including assignment of Joint Commission readiness for each team.
- Provide education to responsible clinical / non-clinical and administrative staff regarding the requirements of the applicable regulations and standards.
- Facilitate and lead teams to fulfill compliance and required metrics as needed. Liaise to the Medical Staff Department, Medical Records Department, and other various departments to assure ongoing regulatory compliance.
- Assist all clinical and non-clinical departments to assure Scope of Service compliance, evaluations and privileging.
- Perform clinical pertinence review function and prepare summary reports for review by Chiefs and Medical Executive Committee.
A successful Accreditation and Regulatory Manager will have:
- Bachelor’s Degree, nursing and clinical experience preferred.
- At least 3 years’ experience with accreditation and licensing survey preparation and implementation in a healthcare setting, as guided by Joint Commission, CMS, payer requirements and metrics.
- Knowledge of organizational learning methods.
- Knowledge of group facilitation techniques.
- Strong interpersonal skills.
- Strong written and oral communication skills.
- Microsoft Office skills including Excel and Access.
Keywords: healthcare compliance, healthcare regulations, regulatory, The Joint Commission, mental health, CMS, Centers for Medicare and Medicaid Services, Massachusetts healthcare, payer requirements