Manager, Hospital Regulatory & Accreditation - Remote US – National

Job Summary

Tenet Healthcare has an immediate opening for a Manager, Hospital Regulatory and Accreditation to support the enterprise. This position will require a high percentage of nationwide travel.

Manager, Regulatory and Accreditation is responsible for assessing, developing, educating, implementing, monitoring, and leading the Tenet Regulatory and Accreditation activities within the company. This includes preparation and survey readiness. The position develops and implements processes for current safe practices in Tenet. The Manager, Regulatory and Accreditation work closely with other corporate departments, groups, and facilities for collaboration and synergy around identified priorities.

• Develops, educates, implements, monitors, and leads, Tenet and USPI, regulatory requirements and accreditation standards, goals, and targets through collaboration with corporate departments and the Sr. Director, Accreditation
• Is a leader for the Clinical Operations Department in the formulation of Tenet and USPI regulatory and accreditation related goals and targets.
• Assists with the development of the Tenet and USPI strategy and tactics for regulatory and accreditation preparation and successful surveys
• Conducts on-site facility surveys
• Provides leadership and expertise in methods of performance improvement.
• Coordinates and collaborates with organizational leaders on activities related to the development, implementation, improvement of and adherence to the organization’s policies and procedures covering the scope of regulatory requirements and accreditation standards
• Supports preparation for surveys (i.e., CMS, TJC, State,)
• Supports the formulation of responses [plans of correction] from surveyors, electronic communication, or third-party payers under the direction of the Sr. Director of Regulatory and Accreditation
• Remains current concerning industry-wide, leading practices
• Demonstrates ethical behavior in decision-making, performance of job responsibilities while maintaining confidentiality regarding patient information, quality, performance, and peer review information.
• Develops policies and procedures for areas of responsibility.
• Develops methods, tools, and other resources for regulatory and accreditation preparedness and sustainment.
• Develops and presents educational material to various audiences based on identified or trending regulatory and accreditation issues.

• Required:
  
  Registered Nurse with advanced degree in relevant field plus five years of regulatory, accreditation, and performance improvement experience.
• A minimum of 75% national travel annually is a requirement. Selected candidate will be required to pass Motor Vehicle Record check and maintain valid driver’s license.
• Experience leading interdisciplinary initiatives in process improvement and directly with improving reliability of healthcare delivery at the point of care.
• Functional knowledge of TJC, CMS COP’s, and other federal and state requirements regulatory standards.
• Relevant experience in healthcare/clinical setting.
• Strong organizational, written, communication, and presentation skills.

• Healthcare Accreditation Certified Professional (HACP-CMS) or Certified Professional Healthcare Quality (CPHQ) within twelve months of hire date.

• Skilled at developing and conducting educational presentations.
• Adept at developing methods, tools, reports, data aggregation and conducting regulatory and operational surveys for USPI facilities, including the review of regulatory requirements and accreditation standards and Conditions of Participation.
• Prepares written reports of clinical and operational survey findings.
  
  Skilled in developing corrective action plans, provide educational programs, monitor implementation of action plan and other oversight activities through follow-up visits to facilities as needed, and provide guidance on regulatory and accreditation communications as needed.
• Expert on regulatory requirements and accreditation standards, preparation activities, and success with surveys.
• Knowledgeable in the areas of peer…