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Manager, Accreditation & Regulatory Compliance, Full Time, Acreditation

Glendale, United States

Nestled between Burbank and Pasadena, Adventist Health Glendale is one of the area's leading healthcare providers. We are comprised of a 515-bed hospital, two urgent cares, home care services, comprehensive cardiology care and a vast scope of services located in the San Fernando Valley. We are committed to the development and empowerment of our nurses and have received Magnet designation from the American Nurses Credentialing Center. Glendale is known for its urban living, with easy access to dining, entertainment, shopping, amusement parks and outdoor recreation. Adventist Health Glendale is proud to be part of the thriving, diverse community since 1905.

Job Summary:

Manages all survey and regulatory compliance with various governmental agencies, including the Joint Commission. Manages improvement processes and programs related to all accreditation preparation and licensing, ensuring sustained compliance with submitted plans of correction. Works closely with nursing, medical staff and other disciplines as part of an organizational team to provide focus and education on accreditation, regulatory and licensing issues. Manages the activities of various levels of assigned personnel utilizing both professional and supervisory discretion and independent judgment. Maintains a dotted line reporting structure to the system director of accreditation, regulatory, and licensing.

Job Requirements:

Education and Work Experience:

Bachelor’s Degree or equivalent combination of education/related experience: Required
Master's Degree: Preferred
Five years' technical experience: Preferred
One year's leadership experience: Preferred

Essential Functions:

Partners with clinical and non-clinical staff to develop, implement, monitor and improve structures required to achieve high quality, safe, cost-effective health care. Assists managers and leaders to mobilize various teams throughout the organization to ensure continuous accreditation standards compliance. Coordinates contract renewal and oversight activities associated with compliance monitoring system.
Provides leadership and expertise in the pursuit and attainment of organizational goals related to accreditation, licensing and regulatory compliance. Manages a team of professionals who collectively safeguard facility licensing status, maintain accreditations/certifications, and assure compliance with a vast range of healthcare regulations.
Identifies opportunities for improvement and utilizes professional knowledge of facility licensing (CDPH), complaint investigation and validation surveys (CMS), Joint Commission accreditation and certifications, Managed Care Medi-Cal certifications (DHCS), and California Children's Services (CCS) certifications.
Addresses key organizational issues, ensuring client and organizational needs are met consistently. Educates the organization on regulatory and accreditation issues.
Performs other job-related duties as assigned.

Organizational Requirements:

Adventist Health is committed to the safety and wellbeing of our associates and patients. Therefore, we require that all associates receive all required vaccinations as a condition of employment and annually thereafter, where applicable. Medical and religious exemptions may apply.

Adventist Health participates in E-Verify. Visit https://adventisthealth.org/careers/everify/ for more information about E-Verify. By choosing to apply, you acknowledge that you have accessed and read the E-Verify Participation and Right to Work notices and understand the contents therein.

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