Manager, Accreditation, Regulatory and Licensure, Fairfield, CA
Manager, Accreditation, Regulatory and Licensure
The Accreditation, Regulatory and Licensure Manager works under the supervision of the Director, Quality Division to ensure that there is a comprehensive management of Accreditation, Regulatory and Licensure activities system wide. The Manager is responsible for regulatory readiness including the maintenance of a system wide calendar of all accreditation, licensure and other regulatory survey activities; ensuring that all required actions are completed on time; functioning as a key point of contact for internal partners on accreditation and licensure related questions, and facilitating the development of action plans to correct non-compliant standards. This position serves as the communication liaison in the Command Center during a survey. The manager is responsible for the supervision of assigned staff.
- Bachelor’s degree or equivalent experience in nursing, public health, health administration, or health related field required.
- Master’s degree preferred
- Minimum of three (3) years of experience with accreditation, licensure and regulatory survey process, development, and follow up of corrective action plans.
- Two (2) years of experience in Quality Improvement, or an equivalent combination of education and experience which would demonstrate the required knowledge, skills and abilities may be qualifying.
- Prior Joint Commission, CMS and CDPH project leadership preferred.
- Strong knowledge of clinical quality and accreditation/regulatory standards.
- Previous supervisory experience preferred.
- Excellent oral and written communication skills required.
- Must possess leadership abilities and high professional standards.
- Must demonstrate the ability to coordinate the work of others.
- Must be highly organized with the ability to set priorities, work independently, and be an effective team member.
- Must possess a high degree of attention to detail.
- Excellent critical thinking and problem solving skills.
- Ability to integrate information from multiple sources.
- Advanced word processing, Excel and Power Point Presentation skills required.
- Ability to work in an Access database preferred.
- Excellent interpersonal skills required in interacting and dealing with administration, medical staff, and hospital personnel as well as external customers and external surveyors.
- Must be assertive and confident in managing complex situations.
- Must be flexible and creative.
- Must have excellent customer service skills.
- Maintains confidentiality of information and is reliable, tactful, and discreet.
- The NorthBay Way is a set of value-based behaviors that are to be consistently demonstrated and role modeled by all employees that work at NorthBay Healthcare. The NorthBay Way principles consist of Caring, Communication, Collaboration, and Competence.
- Occasional attendance at evening meetings or out-of-town conferences.
- Access to operating vehicle with at least minimal coverage auto insurance.