Manager of Regulatory/Accreditation Services Full Time/Day
Location: Davenport, Florida
Internal Number: 21033577
YOU ARE REQUIRED TO SUBMIT A RESUME, LICENSSURE/CERTIFICATION WITH YOUR APPLICATION!
Manager of Regulatory/Accreditation Services at AdventHealth Heart of Florida
Location Address: 40100 US Hwy 27, Davenport, FL 33837
Top Reasons to work at AdventHealth Heart of Florida
Close proximity to Walt Disney World
Various outdoor activities for families and children to enjoy
Beautiful local golf courses available year round
Faith-based work environment
Work Hours/Shift: Full Time
PRINCIPAL DUTIES AND JOB RESPONSIBILITIES:
All essential functions must be performed. Reasonable accommodations may be made to enable individuals with qualified disabilities to perform the essential functions.
Manages, supports and facilitates all processes related to Regulatory and Accreditation requirements such as: The Joint Commission and Center for Medicare and Medicaid Services (CMS) and other federal and local Regulatory agencies.
Serves as primary contact for The Joint Commission; CMS; Safe and Reliable Care; and other partners in improvement, regulatory and accreditation activities.
Works closely with senior level leadership to prepare presentations for meetings such as: Clinical Leadership; MEC; QIC and the Quality Council of the Board.
In collaboration with leadership, acts as internal consultant to the Medical Staff, Administration, all Clinical and Ancillary Departments regarding accreditation and regulatory compliance opportunities.
Manages the analysis and interpretation of accreditation and regulatory opportunities and works closely with quality and other partners to continuously improve and sustain evidence based care and best practices to ensure survey readiness 24/7.
Manages The Joint Commission (TJC) and other Regulatory entities websites to complete timely applications, surveys, preparation and follow-up activities.
Performs the TJC Focused Survey Assessment (FSA) annually and/or other Regulatory Assessment and collaborates, as well as partners with key stakeholders to continuously facilitate improvement activities identified through the assessment(s).
Provides orientation and ongoing education for employees, medical staff, volunteers and other partners regarding Accreditation and Regulatory requirements.
Works in collaboration with the Quality Staff; Clinical and Non Clinical Leadership to develop and implement plans that supports ongoing survey readiness initiatives in alignment with Accreditation and Regulatory requirements.
Support and collaborates with key stakeholders regarding Clinical Performance Improvement initiatives and Corporate Clinical Accountabilities identified by the organization impacting Accreditation and Regulatory requirements.
Serves as liaison to hospital departments to support Accreditation and Regulatory requirements on an ongoing basis.
Seeks and utilizes available resources to identify, manage, support, provide guidance and facilitate ongoing Accreditation and Regulatory requirements to all Clinical and Non Clinical Departments. Pursues educational opportunities for Professional growth.
Manages and facilitates Regulatory and Accreditation committees and/or meetings and serves on various Quality, Patient Safety and Performance Improvement committees.
What Will You Need:
EDUCATION AND EXPERIENCE REQUIRED:
Bachelor of Science in Nursing.
Two (2) years in Quality and Accreditation and Regulatory Management.
Computer literate and proficient in – database management, Electronic Medical Record navigation
Education in HealthCare Services Leadership and Management and/or Performance Improvement such as Team Leader, Facilitatorexperience, Malcolm Baldrige and/or LEAN Six Sigma.
LICENSURE, CERTIFICATION OR REGISTRATION REQUIRED:
· State of Florida License in Registered Nurse or License Practical Nursing
KNOWLEDGE AND SKILLS PREFERRED:
· Experience in Quality; Performance/Lean Improvement; Patient Safety and Human Factor analysis
LICENSURE, CERTIFICATION, OR REGISTRATION PREFERRED:
Certification in Healthcare Quality (CPHQ)
Certification in Healthcare Accreditation
Certification in Patient Safety
Certification in Infection Control
The Quality Manager is accountable for the development, management, and administration of an integrated Compliance, Quality and Risk program. This includes Clinical Engineering Operations and the Medical Equipment Management Program within AdventHealth. Responsible for developing and maintaining a compliance strategy that is responsive to the continuous changes in the organization and corporate structure while maintaining a close customer-responsive relationship. Ensures departmental compliance with codes and regulations of the following organizations; Centers for Medicare Service(CMS), Det Norske Veritas(DNV), Joint Commission and International Standards Organization(ISO). Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all.
At AdventHealth, Extending the Healing Ministry of Christ is our mission. It calls us to be His hands and feet in helping people feel whole. Our story is one of hope — one that strives to heal and restore the body, mind and spirit. Our more than 80,000 skilled and compassionate caregivers in hospitals, physician practices, outpatient clinics, urgent care centers, skilled nursing facilities, home health agencies and hospice centers are committed to providing individualized, wholistic care.