Accreditation and Regulatory Program Manager

Omaha, NE 68124

Posted: 08/14/2023 Industry: Healthcare Executive Job Number: JW25567562

Job Description

Join an award-winning pediatric hospital and the region's pediatric healthcare leader as an Accreditation and Regulatory Program Manager. 

• Award-winning pediatric hospital
• Highly engaged and caring team
• $80000-$118000 plus sign-on/relocation bonus
• Great Benefits
• City offers family fun activities, excellent restaurants, large athletic events like the College World Series and Olympic Swim Trials, a world-class zoo, art and music, and a ton more

• Bachelor’s degree in Nursing, Business, Healthcare Administration, Healthcare Information Management, or a related field from an accredited college or university required, Master’s degree preferred
• Minimum 3 years of experience in the healthcare-related industry required
• Minimum 3 years of experience with health care compliance and regulatory activities required
• Two years of project management experience and/or leadership experience preferred
• Current and valid Nebraska RN license/RN Compact license required if filled by a nurse. 
• Current and valid Basic Life Support (BLS) required if filled by a nurse. 
• Certified as Healthcare Accreditation Certified Professional or equivalent within 3 years of hire.
• Maintains up-to-date knowledge of TJC/CMS regulations for all applicable programs 
• Ensures timely and appropriate communication of all new and updated regulatory requirements to provide guidance to the organization and clinical and non-clinical departments
• Facilitates the development and implementation of newly adopted clinical and non-clinical policies and procedures through active collaboration with the originating departments; facilitates the revision of current policies by providing direction in meeting and maintaining compliance with regulatory requirements
• Primary contact person for regulatory compliance throughout organization and provides direction to designated department leaders, monitors compliance with regulatory requirements at all levels of implementation 
• Maintenance and support of the centralized survey tracer and audit database which provides tools to assist with a consistent assessment of organizational and departmental compliance with regulatory requirements 
• Leads in the internal mock survey program, which includes planning, development of tools, training, conducting mock surveys, reporting findings, and follow-up as needed
• Works with leadership to plan, facilitate, participate, and follow up on findings of consultative surveys which include scheduling, contracting, and billing
• Performs walking rounds regularly to mentor leaders and staff and reinforce expected practices related to TJC, CMS, state law and regulation, and organizational policy/procedure 
• Works with the Marketing Department to maintain and refresh the TJC resources available to staff on the internal intranet site. 
• Leads annual intracycle monitoring, report findings and develop action plans, while monitoring metrics as required
• Oversee TJC website and communicate to appropriate audiences.  Maintains necessary documents
• Leads survey preparations and serves as a leader during an actual survey by escorting and organizing other survey escorts/scribes
• Oversees and provides training to command center staff during a survey 
If you have a background that lines up well with the Accreditation and Regulatory Program Manager description and are interested in learning more about this opportunity, apply below NOW!  
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