Regional Manager Accreditation Regulatory

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Job Title

Regional Manager Accreditation Regulatory

Location

Weston

Facility

Florida Weston Hospital

Department

CRP Quality Assessment-Clinical and Operational Improvement

Job Code

T99282

Shift

Days

Schedule

8:00am-5:00pm

Job Summary

Job Details

Join Cleveland Clinic Weston Hospital’s team of caregivers that remain on the leading edge of technology and education, all while consistently providing patient-centered healthcare. As part of Cleveland Clinic’s Florida region, Weston Hospital is recognized as one of the top hospitals in the Miami-Fort Lauderdale and Florida regions. Here, you will receive endless support and appreciation while building a rewarding career with one of the most respected healthcare organizations in the world.   

As a Regional Manager of Accreditation and Regulatory, you will lead and coordinate accreditation and regulatory readiness efforts across multiple hospitals and care locations within your assigned region. In this pivotal role, you’ll ensure effective processes are in place to evaluate regulatory compliance, sustain continual survey readiness and advance the delivery of high-quality care. You’ll monitor regulatory outcomes, identify opportunities for improvement and drive initiatives that strengthen organizational performance while maintaining full compliance with federal, state and local standards. Through strong documentation, oversight and collaboration, you will help each location uphold a robust and reliable accreditation and regulatory program.

A caregiver in this position works 8:00am to 5:00pm or 7:30am to 4:30pm. No weekend or holidays are required.

A caregiver who excels in this role will:

• Provide consultation and direction to ensure programs and services are implemented at the highest standards and patients receive the highest level of care consistent with regulatory standards.
• Facilitate regulatory compliance by facilitating teams, evaluating practices, assisting in development of new processes and monitoring variances throughout the system.
• Assist in ensuring that daily hospital operations are conducted in accordance with hospital and departmental policies and procedures, safety guidelines, federal, state and local laws and regulations.
• Facilitate professional development and provide coaching to accreditation regulatory team members.

• Partner with stakeholders and ensures that accreditation and the local hospital leadership teams are effective.
• Assist in preparations for Joint Commission surveys.
• Assist to formulate a response to survey activity findings and to quality of care/clinical inquiries from regulatory agencies.
• Ensure accreditation rounding data is trended and made available for review.
• Ensure coordination of survey preparation activities and serves as a liaison with regulatory agencies.
• Ensure all required corrective actions are collected, and reported to appropriate regulatory bodies, as required.
• Ensure staff development, counseling, performance evaluations, and hiring of positions for all direct reporting areas.
• Develop and maintain policies and procedures for areas of responsibility.
• Ensure results of regulatory compliance activities are integrated.
• Facilitate, support, and organize accreditation teams and provides staff support services to such teams.
• Remain current concerning industry-wide, clinical care best practices and evaluates for implementation.
• Educate Governing Board and administrative staff concerning current trends in accreditation and regulatory standards.
• Maintain and regularly update accreditation/regulatory review plans and strategies.
• Work with appropriate education staff to ensure that education activities reflect recommendations formulated by regulatory readiness work teams.
• Develop and track productivity standards for all direct reports.
• Ensure education of regulatory standards and compliance by all direct report departments.

Minimum qualifications for the ideal future caregiver include:  

• Master’s Degree

• Healthcare Accreditation Certified Professional (HACP) OR Certified Joint Commission Professional (CJCP) required within one year of hire date.
• Minimum 5 years previous experience working with The Joint Commission, Healthcare Facilities Accreditation Program (HFAP), and Centers for Medicare and Medicaid (CMS) surveys processes, preferably in a leadership/coordination role. Accreditation certification required. Offset: An additional 5 years of related experience could offset the Master’s Degree requirement
• Excellent analytical, project management and independent problem-solving skills
• Proven demonstration of excellent typing skills, knowledge of Word, Excel, and PowerPoint software programs
• Excellent communication skills

Preferred qualifications for the ideal future caregiver include: 

• Registered Nurse (RN)

• 403(b) Savings & Investment Plan
• Investment Pension Plan (IPP) 
• Tuition Reimbursement
• Paid Time Off (PTO) 
• Employee Discounts
• Dental and Vision Plans 
• Life Insurance and Disability 

Work Skills:  

• Excellent analytical, project management and independent problem-solving skills. Must be able to work in a stressful environment and take appropriate action. Proven demonstration of excellent typing skills, knowledge of Word, Excel, and PowerPoint software programs or equivalents required. Excellent communication skills (oral, electronic and written) including public speaking.
• Ability to demonstrate excellent judgment, attention to process and detail. Discretion, confidentiality, tact, and ability to deal with sensitive issues.
• Demonstrates excellent organizational skills, ability to work independently, and ability to work interdependently.
• Demonstrates ability to interact with all levels of staff and management, and ability to set priorities and manage multiple demands effectively.
• Requires critical thinking skills, decisive judgment and the ability to work with minimal supervision.
• Job requires regular local travel between CCHS facilities.

Physical Requirements:

• Ability to walk extensively,
• Ability to lift up to 25 pounds, and
• Ability to wear protective equipment such as respirators, boots, gloves and protective eye gear

Personal Protective Equipment:

• Must wear personal protective equipment as required by policy

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Keywords: CMS, Accreditation Program, Joint Commission, Joint Survey Preparation

                       

The policy of Cleveland Clinic Health System and its system hospitals (Cleveland Clinic Health System) is to provide equal opportunity to all of our caregivers and applicants for employment in our drug free environment. All offers of employment are followed by testing for controlled substances.

Cleveland Clinic Health System administers an influenza prevention program. You will be required to comply with this program, which will include obtaining an influenza vaccination on an annual basis or obtaining an approved exemption.

Decisions concerning employment, transfers and promotions are made upon the basis of the best qualified candidate without regard to color, race, religion, national origin, age, sex, sexual orientation, marital status, ancestry, status as a disabled or Vietnam era veteran or any other characteristic protected by law. Information provided on this application may be shared with any Cleveland Clinic Health System facility. 

Please review the Equal Employment Opportunity poster. 

Cleveland Clinic Health System is pleased to be an equal employment employer: Women / Minorities / Veterans / Individuals with Disabilities