Manager - Accreditation and Regulatory Affairs

Position Objective:

Under the direction of the VP, Quality & Patient Safety, the Manager develops and implements organizational initiatives to support Luminis Health (LH) accreditation and regulatory continuous readiness. The Manager will work with the LH acute care hospitals, clinicians, clinical support and other health system leaders on the continuous readiness program and ongoing  1) Standard interpretation, 2) Standard compliance, 3) Education and communication about regulatory affairs, and 4) Survey operations. The Manager  emphasizes quality and patient safety at the forefront of regulatory compliance and oversees the day-to-day department program operations and workflow. The Manager directly supervises Accreditation and Regulatory Specialists and is expect to split time on-site at both of the acute care hospitals

Essential Job Duties:

1.    Proactively leads the ongoing evaluation, planning and support of the LH continuous readiness infrastructure and processes to ensure accreditation by deemed status accrediting organizations such as The Joint Commission, CMS, Office of Healthcare Quality, as well as other regulatory accreditation, certifications, and applicable organizational licenses.

2.    Supports workflow needs and develops strengths of content experts and other accreditation and regulatory leaders to support workflow accordingly. Serves as the system accreditation leader during any on-site survey.

3.    Manages system and entity Accreditation and Regulatory Readiness Committees and provides oversight for the accreditation and regulatory specialists to review work plans and progress. Identifies growth and areas of opportunity to ensure Program initiatives are being met.

4.    Provides guidance on accrediting and certification standards interpretation and other regulatory requirements as they apply to organizational practice.

5.    Educates leaders, staff, medical staff and other stakeholders on the accreditation process and requirements.

6.    Partners with regulatory content experts to identify risk areas and support development, implementation and monitoring of regulatory improvement processes.

7.    Ensures regulatory resources are up to date, such as Accreditation Manager Plus (AMP) software program, E-dition standards, and links to the CMS CoPs Interpretive Guidelines and other applicable regulations.

8.    Develops and implements initi

Luminis Health Benefits Overview:
•    Medical, Dental, and Vision Insurance
•    Retirement Plan (with employer match for employees who work more than 1000 hours in a calendar year)
•    Paid Time Off
•    Tuition Assistance Benefits
•    Employee Referral Bonus Program
•    Paid Holidays, Disability, and Life/AD&D for full-time employees
•    Wellness Programs
•    Employee Assistance Programs and more
*Benefit offerings based on employment status

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