Accreditation, Regulatory, and Licensing Specialist V, Clinical (KFHP / H)

Job Summary : In addition to the responsibilities listed above, this role is also responsible for : guiding others to schedule and perform site reviews, medical record reviews, and Physical Accessibility Review (PAR) surveys; independently conducting complex site visits for ambulatory care and affiliated sites, as needed; independently creating, planning, and enacting strategies to ensure survey performance is in accordance with all regulatory requirements through rounds with staff, leaders, and providers; building educational principles for relevant topics (e.g., stroke certifications) to aid staff understanding of organizational priorities; evaluating alignment of patient care with standards and statutes within the program, as well as compliance with regulatory, accreditation programs, and national guidelines; serving as a consultative resource for complex regulatory and accreditation programs, relevant practice guidelines, and order sets; conducting planning and execution of long-term quality and patient safety priorities for Ambulatory Surgery Centers / Units (ASCs or ASUs), in alignment with regional and organizational goals; serving as an internal expert resource for regional strategy development and implementation, including routine surveillance of quality and safety systems; participating in regional cross-functional teams to drive clinical improvements; supporting Graduate Medical Education (GME) for non-physician roles (Hospital Markets Only); independently communicating program status and issues to leadership; and coordinating clinical and service quality improvement activities for regulatory oversight.

Essential Responsibilities :

• Promotes learning by communicating information, providing advice, and building relationships with stakeholders. Listens, responds, seeks feedback, and provides actionable feedback. Practices self-leadership, influences team members, and adapts to changing demands and responsibilities.
• Oversees business-specific projects by applying expertise, ensuring adherence to procedures, making effective decisions, solving complex problems, and developing work plans to meet priorities and deadlines. Recognizes improvement opportunities and influences project completion.
• Serves as subject matter expert for regulations by providing consultation, serving on committees, developing educational content, and anticipating issues related to policies and legislation.
• Develops data management and reporting processes, including data entry, cleaning, analysis, and drafting action plans and recommendations.
• Ensures licensing and accreditation by reviewing requirements, guiding others, conducting gap analyses, and planning for compliance and renewals.
• Improves responses to regulatory audits and survey preparedness by conducting reporting, guiding others, serving as liaison, performing site visits, delivering documentation, assessing workflow gaps, facilitating education, and leading mock surveys to ensure readiness.

Minimum Qualifications :

Additional Requirements :

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