Director Accreditation & Regulatory Organizational Performance
Sutter Health/California Pacific Medical Center
This position is located in San Francisco and will support California Pacific Medical Center by administering and overseeing all activities concerning achieving continuous excellence and survey readiness. The position is responsible for strategic and operational implementation of regulatory requirements, guidelines, and standards, and provides leadership and mentorship for collaborative team relationships in achieving continuous excellence. Working closely with the Quality Department and all levels of management, the Director Accreditation & Regulatory Organizational Performance supports the facilitation, development, and implementation of outcomes through process improvement activities. The position ensures the Board of Directors, medical staff, management and members of the workforce are in a state of continuous compliance with the rules and regulations of regulatory agencies and that company policies and procedures are consistently followed.
The Director Accreditation & Regulatory Organizational Performance will act as an authority and internal resource in the communication of regulatory standards, and oversee a program which is a channel of communication to receive and direct information regarding maintaining standards of excellence to administrative and clinical staff and to regulatory bodies as indicated.
The Director Accreditation & Regulatory Organizational Performance acts as staff to the Officers Council, the Performance Improvement Executive Council (PIEC), the Quality Improvement Committee (QIC) and the Accreditation Steering Committee (ASC) by monitoring and reporting results of the compliance efforts of the Organization, and by providing guidance to the Board and senior management team on matters relating to continuous and ongoing compliance.
- Master’s degree or equivalent is required
Demonstrated Knowledge and Application of:
- Governmental regulations, including CMS; management theory and practice, systems analysis, financial and human resources management and organizational development; Title 22, Conditions of Participation, and applicable regulatory agency requirements; TJC standards and the accreditation process; HIPAA, attorney client privileges; CQI principles; problem assessment and problem solving techniques; policy and procedure development and implementation
- Requires 5 to 10 years of experience in a leadership role in a health care organization or working directly with healthcare organizations
- Strong familiarity with operational, financial, quality assurance, risk management and human resources procedures and regulations is essential
Please contact Angela Hawkins if you are interested in finding out more about this great opportunity.