Regulatory & Cmplnce HC Spec 5

Position Summary:

The University of California, Irvine, a career destination unlike any other, is built upon a rich history of academic and healthcare excellence. We are supported by a globally unique team of academic professionals, researchers, medical experts, and staff. Guided by our mission, vision, and strategic pillars, we thrive in a collaborative environment. We celebrate and leverage the diverse experiences and perspectives of our UCI community to continue to push the boundaries of innovation. Your opportunity to be a part of an award winning team, advancing your career journey, is now!

Reporting to the Director, Risk & Regulatory Affairs, the Accreditation & Regulatory Affairs Manager directs and coordinates accreditation, policy and regulatory affairs initiatives for UC Irvine Health; serves as the organizational liaison with The Joint Commission (TJC), California Department of Public Health (CDPH), and other pertinent regulatory agencies. The incumbent performs a variety of duties including development of strategies for compliance, analysis of accreditation standards, regulations, and policies impacting UC Irvine Health and operations; and collaborates with hospital departments, services, clinics, and business partners in understanding and complying with accreditation standards, regulatory agencies, and hospital policies.

Essential Job Functions:

The identification of essential functions below is not intended to be an exhaustive list of all duties that may be assigned to this position, nor does it restrict the duties which may be assigned to this position if such duties reasonably relate to the position.

• Serves as an internal consultant to clinical (e.g. Nursing, Radiology, Respiratory Therapy) and non-clinical departments (e.g. Facilities, EH&S, Infection Prevention) regarding TJC and CMS interpretation and implementation strategies for compliance
• Performs gap analyses to identify areas of vulnerability in compliance with standards and makes recommendations to Medical Center Joint Commission Function Leaders and/or Senior Management
• Participates in weekly environment of care rounds and auditing activities with leaders of the organization in patient care and ancillary services areas to determine compliance and identification of potential regulatory/accreditation risks; follows up with action items as appropriate.
• Participates in root cause analyses of sentinel events, as appropriate, ensuring adherence to TJC format; relies on experience and expertise to dig deep into issues and find answers
• Monitors compliance and designs/tracks and reports accreditation, licensing, and regulatory performance results to leadership, making recommendations for adjustments as appropriate
• Monitors The Joint Commission (TJC) Sentinel Event alerts and determines what actions are required / appropriate for the organization
• Maintains records of compliance deficiencies, corrective action plans, change status, audits and reporting of monitoring to proper channels
• Keeps informed of changes to regulatory and accreditation requirements to ensure organizational compliance. Functions as an internal expert / resource for interpretation of regulations and accreditation requirements
• Establishes regulatory priorities and budget
• Educates staff on new or revised accreditation, licensing and regulatory requirements/standards. Develops, coordinates and participates in the implementation of educational and training programs to ensure survey readiness at all levels of personnel
• Develops the Health System readiness program and the necessary tools for the assessment of such program
• Develops communication plans to support regulatory compliance priorities and initiatives
• Develops and monitors regulatory and accreditation corrective action plans to eliminate or minimize risk of non-compliance or incompletion; assesses, tracks and monitors corrective action plans for evidence of sustainability
• Analyzes compliance with accreditation standards, licensing and regulatory requirements, and hospital policies through the evaluation of information
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Total Compensation

We offer a wealth of benefits to make working at UCI even more rewarding. These benefits may include medical insurance, sick and vacation time, retirement savings plans, and access to a number of discounts and perks. Please utilize the links listed here to learn more about our compensation practices and benefits.

Required Qualifications:

• Strong knowledge of CMS Conditions of Participation, Federal and State (Titles 22 & 24) regulations, and The Joint Commission accreditation standards. experience in a key role in CMS and Joint Commission surveys
• Must have excellent presentation and computer skills
• Must be able to work flexible hours and locations based on the organization's needs
• Minimum of five years’ experience in a quality or regulatory compliance role within a hospital or health care organization
• Effective written and verbal communication skills; ability to communicate with customers/staff with diverse educational backgrounds
• Demonstrated ability to problem solve, think critically and creatively, and provide leadership through a consultative role
• Bachelor's Degree in a health-related field, RN, or equivalent experience in Quality & Patient Safety
• Ability to manage numerous diverse projects simultaneously through effective priority setting

Preferred Qualifications:

• Recent experience leading a CMS or Joint Commission survey
• Master's Degree in health related field
• Current RN License

Conditions of Employment:

The University of California, Irvine (UCI) seeks to provide a safe and healthy environment for the entire UCI community. As part of this commitment, all applicants who accept an offer of employment must comply with the following conditions of employment:

• Background Check and Live Scan
• Legal Right to Work in the United States
• Vaccination Policies
• Smoking and Tobacco Policy
• Drug Free Environment

The following additional conditions may apply, some of which are dependent upon business unit or job specific requirements.

• California Child Abuse and Neglect Reporting Act
• E-Verify
• Pre-Placement Health Evaluation

Details of each policy may be reviewed by visiting the following page: https://hr.uci.edu/new-hire/conditions-of-employment.php

Closing Statement:

The University of California, Irvine is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, age, protected veteran status, or other protected categories covered by the UC nondiscrimination policy.

We are committed to attracting and retaining a diverse workforce along with honoring unique experiences, perspectives, and identities. Together, our community strives to create and maintain working and learning environments that are inclusive, equitable, and welcoming.

UCI provides reasonable accommodations for applicants with disabilities upon request. For more information, please contact UCI's Employee Experience Center (EEC) at eec@uci.edu or at (949) 824-0500, Monday - Friday from 8:30 a.m. - 5:00 p.m.