Manager of Accreditation Regulatory and Licensing Exempt

CHA Hollywood Presbyterian (CHA HPMC) is a nationally recognized acute care facility that has been caring for the Hollywood community and Los Angeles Areas since 1924.

Join our Global Network and be a CHA Global Ambassador

CHA HPMC is also a part of the world-renown CHA Health System (CHS). CHS has CHA University which consists of 14 education institutions including medical school, nursing school and pharmacy. CHA global network operates 81 hospitals and specialty clinics, 30 research and 31 bio/pharmaceutical/healthcare companies with 14,000 employees in seven countries.

Our New Facility is seeking for Top Talents

The best women’s hospital in Los Angeles is looking for current RN candidates to staff Operating Room, Emergency Department, Labor & Delivery and Mother-Baby care units to be housed in our expanding new patient tower facility scheduled to open next year. Come be a part of this dedicated and caring team right in the heart of Hollywood.

Job Summary

Responsible for leadership, management, and services for accreditation, regulatory, and licensing for state and federal regulatory readiness.  Responsibilities include organizing, planning, directing, and evaluating ongoing readiness and regulatory efforts for inpatient and outpatient services.  Must communicate, guide and assist all departments with regulatory compliance. 

• Demonstrates compliance with Code of Conduct and compliance policies, and takes action to resolve compliance questions or concerns and report suspected violations
• Must demonstrate and maintain knowledge of regulatory and accrediting agencies’ standards related to both hospital and physicians’ services, including comprehensive knowledge of Joint Commission Accreditation procedures and regulations
• Oversees Program Development
• Manages and directs the implementation of JC’s Hospital Accreditation Standards program
• Chairs the monthly Continuous Survey Readiness Committee meetings
• Champion and manage the requirements for certifications and licensure for a variety of organizations, such as Joint Commission (JC), California Department of Public Health (CDPH), CMS, OSHPD, other CDPH branches.
• Directs the planning, development, and implementation of hospital corrective action plans
• Manages compliance with JC and other accrediting organizations, including CMS and the Department of Public Health
• Cultivates and manages hospital relationships with accreditation organizations
• Oversees compliance with the Ethics, Rights, and Responsibilities standards for The Joint Commission
• Administers and facilitates debriefing for all survey preparedness/continuous safety rounding, and completion and submission of the Leapfrog Survey
• Demonstrates success in collaborating with key leaders, in order to define processes and projects to achieve identified goals within specified timelines
• Achieves continuous survey readiness across the organization
• Demonstrates ability to integrate and interpret data from diverse sources addressing issues of high complexity
• Identifies regulatory vulnerabilities and determines escalation level if necessary
• Provides guidance on Joint Commission standards interpretation and other regulatory requirements as they apply to organizational practice/performance
• Actively coordinates the organization’s readiness rounds program and is primarily responsible for the development, communication, implementation and tracking of action plans necessary to close identified gaps in care of compliance with The Joint Commission (TJC) standards and Centers for Medicare and Medicaid Services (CMS) and Title 22 regulations
• Assists in all accreditation and regulatory activities, including surveys, survey preparation and readiness assessments.
• Develops comprehensive accreditation work plans by establishing deliverables, accountabilities, and timelines
• Serves as the contact and point person for Joint Commission accreditation manuals, standards-related publications and newsletters and educational materials; distributes pertinent information
• Maintains and implements department unannounced survey plans
• Manages onsite accreditation and regulatory surveys; supports command center activities
• Manages communications, agendas, and logistics for onsite survey activities
• Finalizes corrective action responses to The Joint Commission and other regulatory agencies for survey and for-cause and complaint investigations
• Prepares the Joint Commission applications or accreditation, updates information accurately
• Performs other duties as assigned.

Minimum Education

Bachelor’s degree from an accredited four-year college or university

Preferred Education

Master’s degree from an accredited four-year college or university

Minimum Work Experience and Qualifications

• 3+ years of recent regulatory experience in an acute health care organization
• Joint Commission and Leapfrog survey experience
• Accreditation activities and survey preparation
• Knowledge of CMS, Title 22, Joint Commission, and Cal OSHA law and regulations

Preferred Work Experience and Qualifications

• 1-3 years Supervisory experience
• Leadership skills.
• Ability to manage multiple projects with competing priorities.

Required Licensure, Certification, Registration or Designation

• Current Los Angeles County Fire Card required (within 30 days of employment).

Disclaimer, Compliance and Service Language:

Salary range is based on years of experience: $86,355 - $128,381 Annually

DISCLAIMER: The above statements are intended to describe the general nature and level of work being performed by incumbents assigned to this job. This is not intended to be an exhaustive list of all the responsibilities, duties and skills required. The incumbent may be expected to perform other duties as assigned.

COMPLIANCE & INTEGRITY: Consistently supports compliance and the Hollywood Presbyterian Medical Center's Code of Conduct by maintaining the privacy and confidentiality of information, protecting the assets of the organization, acting with ethics and integrity, reporting non-compliance, and adhering to applicable federal, state and local laws and regulations, accreditation and licensure requirements (if applicable), and Hollywood Presbyterian Medical Center's policies and procedures.

Models and reinforces ethical behavior in self and others in accordance to the Code of Conduct; adheres to organizational policies and guidelines; supports compliance initiatives; maintains confidences; admits mistakes; conducts business with honesty; shows consistency in words and actions; follows through on commitments.  All Directors, Managers and Supervisors are accountable for communication, implementation, enforcement, monitoring and oversight of compliance policies and practices in their departments.

SERVICE & QUALITY: In addition to defined technical requirements, accountable for consistently demonstrating service behaviors and principles defined by the Hollywood Presbyterian Medical Center, as well as specific departmental/organizational initiatives. Also accountable for consistently demonstrating the knowledge, skills, abilities, and behaviors necessary to provide superior and culturally sensitive service to each other, to our patients, and to purchasers, contracted providers and vendors.

WORKPLACE SAFETY: In addition to defined working conditions and physical requirements, employees are accountable for working safely; following established policies & procedures; utilizing all designated protective personal equipment (PPE) and/or safety equipment assigned for task; and reporting all injuries and hazards to their supervisor immediately.  Supervisors and Managers are accountable for ensuring the safety performance of employees; applying consistent practices in compliance with federal, state and local regulations; providing guidance to maintain a safe and healthy work environment.

Hollywood Presbyterian Medical Center is an equal opportunity employer committed to a diverse and inclusive workforce. Applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy), age, sexual orientation, national origin, marital status, parental status, ancestry, disability, gender identity, veteran status, genetic information, other distinguishing characteristics of diversity and inclusion, or any other protected status.

External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with federal and state laws, as well as applicable local ordinances, including but not limited to the Los Angeles Fair Chance Ordinances.

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