Director Accreditation and Regulatory Compliance

01 Salinas Valley Health Medical Center; Salinas (CA); On-site; USD 115,718 - 144,648; Full time

Job summary

Salinas Valley Health seeks a Director of Accreditation and Regulatory Compliance to lead the development, implementation and enforcement of clinical accreditation programs. The role ensures conformance with state/federal laws and standards such as TJC, Title 22, CMS and CDPH across the hospital.

Responsibilities include directing department workflow, budgeting, staff development and proactive risk mitigation with medical and administrative staff to maintain regulatory readiness.

Qualifications

• Bachelor's Degree required.
• A minimum of two (2) years’ clinical experience plus two (2) years’ managerial experience in an acute care hospital setting required.
• Current California Registered Nurse license preferred.

Responsibilities

• Develop, implement and enforce accreditation and regulatory compliance programs.
• Lead readiness for regulatory and accreditation standards (TJC, Title 22, CMS, CDPH).
• Coordinate and communicate with Joint Commission and other regulators.
• Plan, assign and direct department workflow; manage budget and staff performance.

Education

Bachelor's Degree

Job description

Department: Accreditation & Regulatory

The Director of Accreditation and Regulatory Compliance has primary responsibility for the development, implementation and enforcement of clinical accreditation and regulatory compliance programs. They work to ensure conformance with applicable state and federal laws, regulations and accreditation standards which will include, but are not limited to, The Joint Commission (TJC), Title 22, CMS Conditions of Participation and the California Department of Public Health (CDPH).

Plans, assigns and directs department workflow. Prepares employee annual performance appraisals. Addresses and resolves departmental staff complaints and proactively manages department production and quality control efforts. Sets the standard for departmental behavior and provides and promotes a positive working environment for departmental staff to ensure strong employee morale, motivation and productivity. Holds accountability for the departmental budget and Position Control and takes necessary action to remain within balance and address variances. Responsible for leading continuous, organizational regulatory readiness and compliance to regulatory and accreditation standards. Coordinates verbal and written communication with The Joint Commission (TJC) and other regulatory bodies. Works closely with medical staff, nursing/hospital staff, and department directors and managers to ensure ongoing regulatory and accreditation readiness and compliance. Works in collaboration with key members of the organization to conduct compliance monitoring reviews and develops corrective action plans in response to review findings. Coordinates and participates in the execution of educational activities and the development of educational materials for continuous readiness preparation at all levels of staff, including nursing, other patient care providers, other non-clinical hospital staff as appropriate, Medical Staff and Administration. In collaboration with the Quality Management Department, performs pro-active risk assessment and facilitates design and implementation of action plans. Performs other duties as assigned.

Education: Bachelor's Degree required.

Licensure: Current California Registered Nurse license preferred.

Experience: A minimum of two (2) years’ clinical experience plus two (2) years’ managerial experience in an acute care hospital setting required. Previous successful experience as Director or Manager responsible for hospital’s accreditation and regulatory readiness required.

Pay Range: The hourly rate for this position is $83.86 - $104.83. The range displayed on this job posting reflects the target for new hire salaries for this position.

Job Specifications:

• Union: Non-Affiliated
• Work Shift: Day Shift
• FTE: 1.0
• Scheduled Hours: 40

If you like wild growth and working with happy, enthusiastic over-achievers, you'll enjoy your career with us! Salinas Valley Health, formerly Salinas Valley Memorial Hospital, founded in 1953, is the cornerstone of what would eventually become Salinas Valley Health. Today, we serve thousands of individuals and families just like you throughout the Salinas Valley, Monterey Peninsula and the surrounding region. Each year, our highly trained team of healthcare professionals takes our renowned quality of patient care to the next level. Our team actively utilizes the latest medical techniques with our state-of-the-art technology to improve your health and well-being. In many cases this provides you and your family the opportunity to receive specialized care right here in your own community, without the need for travel. Our 263-bed acute care medical center employs more than 2,036 people and has a medical staff of more than 300 board-certified physicians across a broad spectrum of specialties, all dedicated to your care.