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Accreditation & Regulatory
Under the direction of the Director of Accreditation and Regulatory and organizational leaders, the Accreditation and Regulatory Specialist, Clinical will serve as an internal resource on Joint Commission, CMS, CDPH, and Title 22 standards and is responsible for coordinating all licensure and accreditation activities during surveys and licensing inspections. The Specialist works under the Director of Accreditation and Regulatory to assist in creating, implementing, and maintaining the strategy and tactics to ensure that SVH is continually prepared for Joint Commission accreditation, CDPH licensure, federal and state regulatory surveys,
and compliance with all pertinent regulatory and accreditation requirements. The Specialist must be able to work autonomously under general direction, establishing day-to-day working priorities and long-range planning to achieve timely and quality results. This position will also demand expert writing skills, public speaking, and one-on-one consulting skills.
1. CDPH and CMS Licensing Activities: Collaborates with Director of Accreditation and Regulatory by coordinating the California Department of Public Health (CDPH) and Centers for Medicare and Medicaid Services (CMS) on surveys and evaluations, both announced and unannounced, conducted by
those agencies, including, but not limited to, the following: Serves as coordinator for all matters concerning the state licensure of SVH, works with SVH departments regarding pre-licensing inspections in the hospital and clinics, prepares and submits licensing applications and supplementary profile information when changes are brought about by the creation of new or remodeled patient care locations, change of beds, services, or administrators, new equipment, construction, and other changes that necessitate changes in the hospital license, inspection by CDPH, and special permits or variances. Prepares the application and supporting documents for the annual relicensing of SVH by CDPH and
arranges for payment of the relicensing fee. Ensures that services listed on the hospital license accurately represent the services provided. Prepares, drafts, submits, and renews Program Flexes for approval by CDPH, coordinating as needed with SVH Department managers, Facility Planning, and Health Care Access and Information (HCAI). Formulates and recommends responses to CDPH statements of deficiency and other agency administrative reviews. Investigate situations, processes, and policies, collaborate with SVH leaders and staff to identify effective corrections in response to survey findings, assist departments with implementation of plans of corrections, assimilate information and data, write plans of corrections, reports, and memos, and oversee compliance monitoring activities. Works closely with Facility Planning, Employee Health, and other SVH departments in addressing issues regarding compliance with Title 22 and Title 24 and other issues raised by HCAI. Identifies areas
of noncompliance with existing and newly enacted regulations, recommends corrective measures and monitors corrective actions for compliance with standards, stays informed about changes in federal, state, and local regulations. Responds to CDPH requests for information, including medical records.
Organizes resources for surveys. Establishes and maintains an effective, collaborative working relationship with CDPH and CMS to successfully address licensing efforts, Title 22 and Title 24 compliance, and state-mandated reporting of events.
2. Joint Commission Accreditation Activities: Collaborates with the Director of Accreditation and Regulatory in coordinating all Joint Commission preparedness and onsite survey activities including, but not limited to, the following: training SVH staff in Accreditation and Regulatory practices, training a
survey leadership team, training and maintaining an EMR Super User Survey Team, Joint Commission standards staff education, setting up a Command Center during surveys, Focused Standards Assessments template creation, distribution, tracking, and follow-up, conducting mock interviews, maintaining
required documents both hard copy and electronic, scheduling consultants, dissemination and tracking of all Joint Commission Plans of Correction for the hospital, compliance monitoring, responding to complaints, creating internal communication materials, Joint Commission survey readiness activities.
Serves as a Joint Commission SME and responds to regulatory inquiries from SVH leadership and staff.
3. Internal Auditing, Consulting, Training, and Education Activities: Participates in Accreditation and Regulatory activities including, but not limited to, the following: internal auditing, consulting, training of staff, coaching, education, and rounding activities by doing the following: serve as lead Accreditation
and Regulatory representative for all rounding activities (pharmacy, infection prevention, fire drills, and environmental rounds), conducts patient and equipment tracers, creates regulatory educational, communication, and marketing documents, develops PowerPoint presentations and presents to a variety
of groups, committees, and departments, analyzes and synthesizes regulations, trains new Accreditation and Regulatory staff. Conducts regular audits and reports any compliance discrepancies and collaborates with relevant teams to implement corrective actions, completes validation reports. Provides
consultation for risk assessments, waivers, or policy deviations when needed in collaboration with department or unit leaders.
4. Regulatory and Accreditation Activities: Provides back-up coverage for the Accreditation and Regulatory director. Research national and international healthcare trends, track and trend risks by using the Safer Matrix method, educate others on new policies, interpretive guidelines, and regulatory
trends, and represent SVH to outside regulatory agencies. Collaborate with unit and department managers to consistently communicate culture of safety initiatives. Prepares and distributes reports to appropriate committees, directors and managers.
5. Analytics and Data: Analyzes tracer and rounding data: creates reports for executive-level administrators and Medical Staff Administration committees, uses the Safer Matrix model to analyze level of risk for each chapter of hospital accreditation standards, uses Excel to track, trend, and graph data, conducts Root Cause Analysis to problem solve areas of low compliance, uses software technology such as mobile apps, desktop products and EMR to improve quality and safety measures. Utilizes data resources within the organization which will aide in presenting data to directors and managers in order to maintain compliance with accreditation and regulatory requirements. Responsible for maintaining
ConVerge, the regulatory software program.
6. Participates in RCAs, FMEAs, HVAs and patient safety activities as assigned by the director.
7. Other duties as assigned.
Education: Bachelor’s Degree required in a healthcare related field.
Licensure: Current California RN license required.
Certification: Healthcare Accreditation Certification Professional (HACP) preferred.
Experience: Three (3) years of acute care clinical RN experience (bedside/direct patient care or nursing management) in an acute care setting required. Previous Regulatory and Accreditation experience preferred.
Pay Range: The hourly rate for this position is $70.00 - $90.00 The range displayed on this job posting reflects the target for new hire salaries for this position.
Job Specifications:
If you like wild growth and working with happy, enthusiastic over-achievers, you'll enjoy your career with us!
