REGULATORY AND ACCREDITATION MANAGER

REGULATORY AND ACCREDITATION MANAGER

POSITION OVERVIEW

The Regulatory Compliance Manager develops and ensures processes to support constant survey readiness infrastructure and is responsible for collecting, organizing, documenting, analyzing, and reporting data pertaining to Regulatory Agencies. and coordinates quality improvement activities in conjunction with Director Quality Resources. Responsibilities include : conducting chart reviews as needed; analyzing data for outcomes; supporting accreditation and regulatory compliance, hospital goals, and other improvement initiatives through compiling, monitoring and reporting data; assisting to identify patient safety issues; facilitating Failure Mode Effect Analysis, Quality Improvement Teams, and Root Cause Analysis processes to effect changes leading to quality improvement.

EXEMPTION STATUS

Non-exempt

REQUIREMENTS

Education :

Associates degree in healthcare related field required

Bachelor's degrees preferred

Training in quality management and / or statistical analysis preferred

Experience :

Some experience with Quality Improvement processes required.

Knowledge, skills and abilities required :

Strong problem solving skills

Ability to apply critical thinking in a variety of situations

Effective communication skills with all levels of staff

Computer competency with basic office products(Microsoft office, word, excel, power point, publisher); ability to quickly learn proprietary tools

Capability to perform statistical analysis

Knowledge of medical terminology

Strong Customer Relation skills

Ability to facilitate all levels of staff appropriately through improvement processes

Strong project management skills, with the ability to manage, prioritize, and follow through multiple tasks

Licensure / Certification :

Registered nurse in Virginia or compact state of residence required

CPHQ preferred

Regulatory certification preferred (required with 3 years in position)

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