Regulatory and Accreditation Manager

We've made a lot of progress since opening the doors in 1942, but one thing has never changed - our commitment to serve, heal, lead, educate, and innovate.  We believe that every award earned, every record broken and every patient helped is because of the dedicated employees who fill our hallways. 

At Ochsner, whether you work with patients every day or support those who do, you are making a difference and that matters.  Come make a difference at Ochsner Health and discover your future today! 

This job ensures system-wide compliance of environmental safety regulations, including Environment of Care and Life Safety Code standards from The Joint Commission (TJC), United States Pharmacopeia (USP) 800 and hazardous waste disposal regulations, and laser safety. Evaluates and assesses current compliance, implementing necessary changes and identifying potential risks to meet regulatory expectations.

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential duties.

This job description is a summary of the primary duties and responsibilities of the job and position. It is not intended to be a comprehensive or all-inclusive listing of duties and responsibilities. Contents are subject to change at the company’s discretion.

Education

Required – High school diploma or equivalent.

Work Experience

Required – 5 years of experience in regulatory healthcare, facilities, plant engineering or related.

Certifications

Preferred – Certified Hospital Safety Professional (CHSP), Certified Hospital Fire Safety Professional (CHFSP), or Certified Hospital Facility Manager (CHFM).

Knowledge Skills and Abilities (KSAs)

• Working knowledge of current regulations, including The Joint Commission (TJC), USP <800>, Centers for Medicare & Medicaid Services, National Fire Protection Association, etc.

• Strong interpersonal skills.

• Ability to effectively interact with multiple stakeholders and customers and demonstrate appropriate emotional intelligence in varied situations.

• Proficiency in using computers, software, and web-based applications.

• Strong verbal and written communication skills.

• Organizational and time management skills.

Job Duties

• Serves as the USP <800> designated person for the company and remains current in and ensures compliance with USP <800> and other applicable laws, regulations, and standards, including but not limited to The Joint Commission (TJC), Centers for Medicare & Medicaid Services (CMS), and Louisiana Department of Health (LDH).

• Completes and prepares mock survey reports, conducts regulatory rounding site visits, and documents review.

• Maintains reports of environmental testing and wipe sampling performed and develops and implements action plans responding to environmental testing and wipe sampling results.

• Ensures environmental control of the storage and compounding areas, participates in regulatory agency inspections of the compounding facility and oversees and uses internally developed systems and/or commercial vendor software to maintain records of facility monitoring.

• Develops and implements appropriate standard operating procedures for risk prevention, updates policies, procedures and other documentation requirements to align with changes in standards, regulations and/or laws and communicates risks that may compromise safety as well as the rationale for prevention policies.

• Participates in TJC, LDH/CMS, and/or other accrediting body licensing surveys, and assists and actively participates in the System Environment of Care Committee.

• Addresses system-level compliance with other regulatory concerns, including laser safety, USP <800> and hazardous waste disposal, reports potentially hazardous situations to the management team, and collaborates with health care professionals to provide training regarding risks to themselves and others resulting from non-compliance.

• Ensures personnel competency and uses internally developed systems and/or commercial vendor software to track personnel competency.

• Performs other related duties as required.

The above statements describe the general nature and level of work only. They are not an exhaustive list of all required responsibilities, duties, and skills. Other duties may be added, or this description amended at any time.

Remains knowledgeable on current federal, state and local laws, accreditation standards or regulatory agency requirements that apply to the assigned area of responsibility and ensures compliance with all such laws, regulations and standards.

This employer maintains and complies with its Compliance & Privacy Program and Standards of Conduct, including the immediate reporting of any known or suspected unethical or questionable behaviors or conduct; patient/employee safety, patient privacy, and/or other compliance-related concerns.

The employer is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, protected veteran status, or disability status.

Physical and Environmental Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Light Work - Exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently, and/or a negligible amount of force constantly (Constantly: activity or condition exists 2/3 or more of the time) to move objects. Physical demand requirements are in excess of those for Sedentary Work. Even though the weight lifted may be only a negligible amount, a job should be rated Light Work: (1) when it requires walking or standing to a significant degree; or (2) when it requires sitting most of the time but entails pushing and/or pulling of arm or leg controls; and/or (3) when the job requires working at a production rate pace entailing the constant pushing and/or pulling of materials even though the weight of those materials is negligible. NOTE: The constant stress and strain of maintaining a production rate pace, especially in an industrial setting, can be and is physically demanding of a worker even though the amount of force exerted is negligible.

Normal routine involves no exposure to blood, body fluid or tissue, but exposure or potential for exposure may occur.

The incumbent works with patients who have known or suspected communicable diseases and may enter isolation rooms.  The incumbent has an occupational risk for exposure to all communicable diseases.

Because the incumbent works within a healthcare setting, there may be occupational risk for exposure to hazardous medications or hazardous waste within the environment through receipt, transport, storage, preparation, dispensing, administration, cleaning and/or disposal of contaminated waste. The risk level of exposure may increase depending on the essential job duties of the role.

Are you ready to make a difference? Apply Today!

Ochsner Health does not consider an individual an applicant until they have formally applied to the open position on this careers website.

Please refer to the job description to determine whether the position you are interested in is remote or on-site. Individuals who reside in and will work from the following areas are not eligible for remote work position: Colorado, California, Hawaii, Illinois, Maryland, Massachusetts, Minnesota, New Jersey, New York, Vermont, Washington, and Washington D.C.

Ochsner Health endeavors to make our site accessible to all users.  If you would like to contact us regarding the accessibility of our website, or if you need an accommodation to complete the application process, please contact our HR Employee Solution Center at 504-842-4748 (select option 1) or [email protected]. This contact information is for accommodation requests only and cannot be used to inquire about the status of applications.

Ochsner is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to any legally protected class, including protected veterans and individuals with disabilities.