Manager, Accreditation and Compliance

Job Description

Location: UC Health
Department: Accreditation and Regulatory Affairs
Hours: Full-time, 40 hours a week
Shift: First Shift

Under the supervision of the Enterprise Director of Regulatory and Accreditation, the Manager of Accreditation and Regulatory Affairs manages and coordinates the organizational effort to assure continuous compliance with Joint Commission standards, CMS Regulations and any other regulatory bodies. Project manages campus integration including hospital based ambulatory care.

Responsibilities

Accreditation and Regulatory Compliance - 50% Serves as the organizational resource on interpretation of Joint Commission standards, CMS Conditions of Participation and ODH by developing and maintaining expert knowledge Manages, coordinates and directs operational and patient care services in ongoing survey readiness. Serves at the organization liaison to UC Health Corporate Compliance department. Assists them with the development of auditing priorities, action plans and ongoing audits to ensure compliance. Develops regulatory reports to be presented to UC Health Governing Body. Provides education and collaboration to hospital departments and managers to assure current knowledge of appropriate standards. Designs, organizes and implements systems for tracking, evaluation and reporting efforts and outcomes relative to standards set by accrediting and regulatory agencies. Assures continuous readiness thru ongoing evaluation of compliance. Provides reports and feedback to Senior Leadership regarding readiness status including timely reports of gaps or potential gaps in readiness.

Project Management for Campus Integration - 40% Responsible for the project management of campus integration including hospital based ambulatory care. Chairs weekly meeting with hospital ambulatory care practice leadership to address any opportunities in the on-boarding process and transition. Establish priorities that align with UC Health's current direction and need. Contribute to the management of organizational changes and operational processes. Direct individuals and departments in the establishment, implementation and stabilization of new services and processes. Work closely with and reports to Senior Leadership to monitor the progress to ensure regulatory compliance from all aspects of TJC, CMS, ODH and Ohio Board of Pharmacy. Independently coordinate projects of high complexity.

Education and Communication - 10% Provides education and mentoring to managers, staff and physicians to assure attainment of program goals. Conducts audits to ensure regulatory compliance. Develops and reports effective outcome measures for the regulatory compliance program. Coordinates Physician annual education to ensure regulatory compliance. Utilizes diverse communication and education strategies to assure the integration of regulatory compliance practices by all staff, volunteers and physicians utilizes systems thinking to identify causes and solution to errors. Utilizes statistical processes and uses dynamic data displays to provide information to front line care givers in a timely manner. | Review the physical demands and assign an overall average percentage of time this position performs these activities. These physical demands will not be listed or rated on the annual performance appraisal. Climbing: Ascending or descending stairs, ladders, ramps, etc, using feet and legs and /or hands and arms - 10% Stooping: Bending body downward and forward by bending spine at the waist - 5% Kneeling: Bending legs at knees to come to a rest on knee or knees - 5% Reaching: Extending hand(s) and arm(s) in any direction - 10% Standing: Remaining upright on the feet, particularly for sustained periods of time - 10% Walking: Moving about on foot to accomplish tasks - 10% Pushing 0-10 lbs: Use of upper extremities to press against something with steady force in order to move something forward, downward or outward - 0% Pushing 11-20 lbs: Use of upper extremities to press against something with steady force in order to move something forward, downward or outward - 5% Pushing 21-50 lbs: Use of upper extremities to press against something with steady force in order to move something forward, downward or outward - 0% Pushing 51 lbs or more: Use of upper extremities to press against something with steady force in order to move something forward, downward or outward - 0% Pulling: Use of upper extremities to exert force in order to drag, haul or tug objects in a sustained motion - 5% Lifting 0-10 lbs: Raising objects from a lower to a higher position, or moving objects horizontally from position-to-position and requires the use of upper extremities and back muscles - 0% Lifting 11-20 lbs: Raising objects from a lower to a higher position, or moving objects horizontally from position-to-position and requires the use of upper extremities and back muscles - 5% Lifting 21-50 lbs: Raising objects from a lower to a higher position, or moving objects horizontally from position-to-position and requires the use of upper extremities and back muscles - 0% Lifting 51 lbs or more: Raising objects from a lower to a higher position, or moving objects horizontally from position-to-position and requires the use of upper extremities and back muscles - 0% Carrying 0-10 lbs: Holding and moving/transporting an object about - 5% Carrying 11-20 lbs: Holding and moving/transporting an object about - 0% Carrying 21-50 lbs: Holding and moving/transporting an object about - 0% Carrying 51 lbs or more: Holding and moving/transporting an object about - 0% Fingering: Picking, pinching, typing or otherwise working primarily with fingers rather than with the whole hand or arm, as in handling - 75% Feeling: Perceiving attributes of objects such as size, shape, temperature or texture by touching with skin, particularly that of (using) fingertips - 50% Talking: Expressing or exchanging ideas by means of the spoken word - must convey detailed or spoken instructions to others accurately, loudly or quickly - 100% Hearing: Perceiving the nature of sounds at normal speaking levels with or without correction, and having the ability to receive detailed information through oral communication - 100% Seeing: The process of perceiving objects by use of the eyes to perform an activity - visual acuity requirements include ability to discern position of object(s), shape of object(s), color, depth perception or visual inspection - 100%

Qualifications

Minimum Requirement: Bachelor's Degree in Nursing is required. ? Preferred: Master's Degree. | Current RN License. | Minimum Requirement: 3 - 5 Years equivalent experience. 5 years clinical experience preferred in multiple areas plus 2 years of line or project management experience. ? Preferred: 3 - 5 Years equivalent experience in clinical data analysis experience in hospital/health care setting preferred. Formal training or experience in patient safety.