Director, Regulatory and Accreditation
Company: Concord Hospital
Posted on: November 23, 2022
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
- 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
- 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
- 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
- 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
- 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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