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Manager, Accreditation, Regulatory and Licensure, Fairfield, CA


NorthBay Healthcare

Manager

Fairfield, CA

April 3, 2019


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Manager, Accreditation, Regulatory and Licensure

Job Summary:

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.

Education:

  1. Bachelor’s degree or equivalent experience in nursing, public health, health administration, or health related field required.
  2. Master’s degree preferred

Experience:

  1. Minimum of three (3) years of experience with accreditation, licensure and regulatory survey process, development, and follow up of corrective action plans.
  2. 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.
  3. Prior Joint Commission, CMS and CDPH project leadership preferred.
  4. Strong knowledge of clinical quality and accreditation/regulatory standards.
  5. Previous supervisory experience preferred.

Skills:

  1. Excellent oral and written communication skills required.
  2. Must possess leadership abilities and high professional standards.
  3. Must demonstrate the ability to coordinate the work of others.
  4. Must be highly organized with the ability to set priorities, work independently, and be an effective team member.
  5. Must possess a high degree of attention to detail.
  6. Excellent critical thinking and problem solving skills.
  7. Ability to integrate information from multiple sources.
  8. Advanced word processing, Excel and Power Point Presentation skills required.
  9. Ability to work in an Access database preferred.

Interpersonal Skills:

  1. Excellent interpersonal skills required in interacting and dealing with administration, medical staff, and hospital personnel as well as external customers and external surveyors.
  2. Must be assertive and confident in managing complex situations.
  3. Must be flexible and creative.
  4. Must have excellent customer service skills.
  5. Maintains confidentiality of information and is reliable, tactful, and discreet.
  6. 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.

Other:

  1. Occasional attendance at evening meetings or out-of-town conferences.
  2. Access to operating vehicle with at least minimal coverage auto insurance.

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