What are the responsibilities and job description for the Manager, Accreditation & Regulatory Compliance position at Adventist Health?
Sierra Vista
Nestled on the Central California Coast, Adventist Health Sierra Vista has been providing care to our community since 1959. Our 162-bed acute care facility includes a Level III Neonatal Intensive Care Unit and county designated trauma center. San Luis Obispo offers the excitement of a lively community while being a fifteen-minute drive from the serenity of Avila Beach, known for their natural hot springs, and Pismo Beach, known for their sand dunes and eucalyptus trees. Featuring a charming downtown, comfortable coastal weather, idyllic views, and an active lifestyle San Luis Obispo offers much to be had.
Twin Cities
Located in Templeton amongst the oak trees, Adventist Health Twin Cities has been serving northern San Luis Obispo County since 1977. Comprised of a 122-bed acute care facility, our team provides exceptional care in emergency medicine, orthopedics, obstetrics, digestive disorders, wound care, and various medical, surgical and outpatient services. Locals enjoy weekly farmers markets in downtown Templeton, farm-to-fork dining, beautiful landscapes for hiking and biking, and beach days just fifteen minutes away at Cambria and Morro Bay.
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.
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, including, but not limited to, measles, mumps, flu (based on the seasonal availability of the flu vaccine typically during October-March each year), COVID-19 vaccine (required in CA, HI and OR) etc., as a condition of employment, and annually thereafter. Medical and religious exemptions may apply.
