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Director, Regulatory and Accreditation

Company: Concord Hospital
Location: Concord
Posted on: November 23, 2022

Job Description:

SummaryThe Director, Regulatory and Accreditation for Concord Hospital and Concord Hospital Medical Group, provides leadership and strategic direction for regulatory processes, including DVN GL, ISO 9000, CMS and other state and regulatory accreditations. -The Director, designs, directs, and facilitates implementation of effective systems to evaluate regulatory compliance, risk management, and continuous survey readiness. -This position collaborates with the other CH and CHMG Directors and interface with system Risk Management, Compliance, and Quality and Operational Excellence departments.Education and ExperienceMaster's degree in Nursing required or equivalent; four to six years related experience and/or training; or equivalent combination of education and experience. - Two to four years' experience in accreditation or regulatory management.Essential Duties and ResponsibilitiesEssential Duties and Responsibilities include the following.Other duties may be assigned.

  • Assists in review of Health Services Division, CMS and Health System policies and ensure currency and compliance with all requirements.
  • Conducts ongoing assessment as to the state of compliance to all applicable regulations and standards for DNV and ISO 9000 for the health system.
  • Leads supports and operationally manages key regulatory readiness strategies that promote effective compliance with state and federal regulations (Conditions of Participation) maintaining continuous readiness.
  • Identifies areas of vulnerability and assists leadership in developing corrective action plans.
  • Identifies areas of success to recognize and encourage promotion/ sharing of best practices.
  • Ensures that processes needed for the meeting accreditation standards are established, implemented and maintained. - Reports to senior management on the performance of these and any need for improvement/ action. -
  • Investigates and responds to regulatory complaints, required action plans and requests for information.
  • Assists leaders/ managers in development of specific educational strategies to address areas of vulnerability for compliance with standards and staff education needs on applicable standards.
  • Coordinates DNV GL survey preparation by organizing key staff/ groups, education staff, acting as a resource and acting in collaborative fashion to prepare the organization for surveys.
  • Develops information and management reports that are meaningful and assist in management of operations and regulatory standards.
  • Serves as a resource to organization for regulatory concerns and consultant to assist in achieving and maintaining regulatory compliance by providing interpretation, information, education and tools to Senior Leadership, Department Directors, and Managers.
  • Collects, analyzes and trends data regarding regulatory compliance data with the standards.
  • Updates and maintains personal knowledge of regulatory standards and issues by anticipating new regulations and presenting a strategy for compliance.
  • Maintains presence at regional and national meetings that pertain to DNV GL.
  • Establishes effectively collaborates and communicates with all levels of the organization.
  • Acts as organizations liaison to accrediting and other regulatory organizations.Concord Hospital is an Equal Employment Opportunity employer. It is our policy to provide equal opportunity to all employees and applicants and to prohibit any discrimination because of race, color, religion, sex, sexual orientation, gender, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status.Applicants to and employees of this company are protected under federal law from discrimination on several bases. Follow the link above to find out more.If you are an individual with a disability and require a reasonable accommodation to complete any part of the application process, you may contact Human Resources at 603-230-7269.

Keywords: Concord Hospital, Concord , Director, Regulatory and Accreditation, Executive , Concord, California

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