Director of Quality, Regulatory Affairs and Accreditation

Applicants may apply for this position by submitting a resume/ CV to the following email address:

When submitting a resume/CV by email, you must include the job title and posting number in the subject line of your email . An application or resume/CV must be filed for each position which interests you.

To receive Veteran Preference, appropriate discharge papers must be attached to the online application or must be included with your emailed resume/CV. Please refer to Veteran Preference document requirements listed on the bottom of this posting.

Job Summary

Under the direction of the Chief Quality Officer, directs the strategic management and planning for Joint Commission Accreditation and accreditation related activities for all clinical services throughout the health system, including hospitals, clinics, behavioral health centers and ambulatory surgery centers. Sets guidelines to meet requirements for Joint Commission Accreditation leading to successful accreditation for all entities within the health system. Develops and maintains a comprehensive accreditation project plan adhering to standards, prioritized interventions and on-going monitoring for compliance as established by Joint Commission for all accreditation requirements. Develops and manages a plan to assure compliance with Centers for Medicare and Medicaid Services (CMS) Conditions of Participation. Coordinates efforts to earn outstanding clinical performance and a positive customer experience as required for accreditation. Coordinates efforts to assure regulatory compliance with standards established by our managed care partners.

General Administrative Responsibilities

Collective Bargaining

1. Review applicable Collective Bargaining Agreements and consult with Labor Relations to generate management proposals
2. Participate in collective bargaining negotiations, caucus discussions and working meetings

Discipline

1. Document, recommend and effectuate discipline at all levels
2. Work closely with labor relations and/or labor counsel to effectuate and enforce applicable Collective Bargaining Agreements
3. Initiate, authorize and complete disciplinary action pursuant to CCH system rules, policies, procedures and provision of applicable collective bargaining agreements

Supervision

1. Direct and effectuate CCH management policies and practices
2. Access and proficiently navigate CCH records system to obtain and review information necessary to execute provisions of applicable collective bargaining agreements

Management

1. Contribute to the management of CCH staff and CCH' systemic development and success
2. Discuss and develop CCH system policy and procedure

General Administrative Responsibilities continued

1. Consistently use independent judgment to identify operational staffing issues and needs and perform the following functions as necessary; hire, transfer, suspend, layoff, recall, promote, discharge, assign, direct or discipline employees pursuant to applicable Collective Bargaining Agreements
2. Work with Labor Relations to discern past practice when necessary

Typical Duties

1. Establishes guidelines to meet Joint Commission accreditation requirements
2. Develops and leads a regulatory survey readiness program in support of the organization's mission, values and business objectives
3. Develops and maintains a comprehensive project plan linked to standards with on-going monitoring and reporting to senior management
4. Serves as the System's resource in questions related to accreditation and to CMS standards
5. Works with CCHHS senior management and clinical staff in leading and managing all aspects of the accreditation process and standard adherence
6. Coordinates activities with subject matter experts and unit business owners
7. Conducts training and coaching to support understanding of accreditation standards and requirements
8. Develops and maintains plans to assure compliance with regulatory requirements of managed care plans
9. Develops and manages audit activities to ensure compliance with accreditation standards and develops and maintains a dashboard to demonstrate ongoing compliance
10. Facilitates communication of information among governance committees and serves as liaison on accreditation issues and changing standards
11. Maintains accreditation and audit document library
12. Maintains and updates policy library
13. Performs other duties as they might be assigned

Reporting Relationship

Reports to the Chief Quality Officer