Director, Accreditation & Regulatory Standards

Job Profile Summary

Plans, implements, and directs activities that supports the Medical Center’s compliance with state and federal regulatory requirements and associated accreditation requirements.

This includes, but is not limited to, acting as the on-site survey coordinator, acting as a resource and consultant to the organization, acting as a liaison between the organization and its accreditation or regulatory bodies.

Plans, implements, and directs, the Health System Policy and Clinical Resource Document programs to ensure compliance with regulations and legal statute.

Ensures evidence based practice is fundamental in resource document processes. Works with Medical Center leadership for policy initiatives and ongoing execution of plans.

• Plans, implements and directs programs to support continuous survey readiness activities in collaboration with subject matter experts across the organization
• Implements educational programs and current resources to support regulatory compliance and survey readiness as part of day-to-day operations
• Directs organizational survey readiness and continuous compliance activities including ongoing monitoring through observations of clinical and clinical support areas
• Serves as an expert in identifying high risk and patient safety sensitive processes and ensures activities are in place for ongoing risk assessment
• Partners with Medical Center Leadership to implement risk reduction and continuous compliance activities
• Partners with Medical Center Leaders to respond to significant Patient Safety Events that may be subject to regulatory agency oversight
• Leads on-site planned and for-cause surveys and inspections in coordination with Medical Center Leaders and subject matter experts.
• Leads post-survey activities including, but not limited to collaboration with leaders on the development of action plans, authoring corrective action plans and other standards compliance plans, and coordination of follow up survey / inspection plans.
• Serves as the organization’s point of contact for accreditation and regulatory agencies and other external partners.
• Provides oversight of the UVA Health System Policy Program and management processes including working with legal counsel and partners across the Health System and University.
• Leads, facilitates, and supports organization and System level programs and projects integral to standardizing safe clinical practices and achieving and maintaining regulatory compliance.
• Administers the organization’s approved electronic Policy and Clinical Document repository.
• Implements Policy and Clinical Document continuous improvement processes in partnership with Medical Center leadership

Position Compensation Range : $109,116.80 - $174,595.20 Annual

MINIMUM REQUIREMENTS

Education : Bachelor's degree.

Experience : 3 to 7 years of clinical and / or administrative experience specific and related to accreditation and regulatory bodies, such as CMS, state licensing agencies, and Joint Commission

Licensure : None required.

PHYSICAL DEMANDS

This is primarily a sedentary job involving extensive use of desktop computers. The job does occasionally require traveling some distance to attend meetings, and programs.

The University of Virginia, i ncluding the UVA Health System which represents the UVA Medical Center, Schools of Medicine and Nursing, UVA Physician’s Group and the Claude Moore Health Sciences Library, are fundamentally committed to the diversity of our faculty and staff.

We believe diversity is excellence expressing itself through every person's perspectives and lived experiences. We are equal opportunity and affirmative action employers.

All qualified applicants will receive consideration for employment without regard to age, color, disability, gender identity or expression, marital status, national or ethnic origin, political affiliation, race, religion, sex (including pregnancy), sexual orientation, veteran status, and family medical or genetic information.