Manager of Accreditation and Regulatory Information, Accreditation and Medical Library, Full-Time, Days

ABOUT MARINHEALTH
Are you looking for a place where you are empowered to bring innovation to reality? Join MarinHealth, an integrated, independent healthcare system with deep roots throughout the North Bay. With a world-class physician and clinical team, an affiliation with UCSF Health, an ever-expanding network of clinics, and a new state-of-the-art hospital, MarinHealth is growing quickly. MarinHealth comprises MarinHealth Medical Center, a 327-bed hospital in Greenbrae, and 55 primary care and specialty clinics in Marin, Sonoma, and Napa Counties. We attract healthcare’s most talented trailblazers who appreciate having the best of both worlds: the pioneering medicine of an academic medical center combined with an independent hospital's personalized, caring touch. 

MarinHealth is already realizing the benefits of impressive growth and has consistently earned high praise and accolades, including being Named One of the Top 250 Hospitals Nationwide by Healthgrades, receiving a 5-star Ranking for Overall Hospital Quality from the Centers for Medicare and Medicaid Services, and being named the Best Hospital in San Francisco/Marin by Bay Area Parent, among others. 

Company:

Marin General Hospital dba MarinHealth Medical Center

Compensation Range:

$54.32 - $81.48

Work Shift:

8 Hour (days) (United States of America)

Scheduled Weekly Hours:

40

Job Description Summary:

Accreditation and Regulatory
Manages and collaborates with the Director Quality Management Services in the development and management of data systems that support ongoing regulatory compliance. Performs analytical and project management work that supports the function of the Accreditation program. Manages and coordinates the assessment, measurement, and reporting of ongoing compliance with the Joint Commission accreditation standards and other state and federal regulatory requirements.

Job Requirements, Prerequisites and Essential Functions:

Job Specifications:

Education:

• Bachelor’s degree required.

Experience

• Five years experience in a management or leadership role within a hospital or health care organization with responsibility for accreditation and regulations related to healthcare.

License and Certifications:

• NA

Prerequisite Skills

• Knowledge of Joint Commission standards and survey process

• Excellent analytical, project management and independent problem-solving skills

• Ability to review medical records and abstract pertinent clinical and other information using regulatory assessment tools, audits and monitoring activities

• Ability to work with others in developing appropriate data collection and assessment tools to support compliance activities in response to dynamic regulatory requirements

• Knowledge of Word, Excel, and PowerPoint software programs or equivalents

• Excellent communication skills (oral, electronic and written)

• Ability to demonstrate excellent judgment, attention to process and detail

• Demonstrates ability to apply discretion, confidentiality, tact, and ability to deal with sensitive issues

• Demonstrates ability to work independently, and ability to work interdependently

• Demonstrates evidence of continuing professional development

• Demonstrates excellent customer service skills

• Ability to set priorities and manage multiple demands effectively

• Ability to function autonomously and take initiative

• Ability to work collaboratively with hospital staff, physicians, and outside agencies

• Ability to manage change through collaborative and positive leadership skills

• Ability to take initiative in leading the organization while being a team player and can work as a team member across organization lines

• Demonstrates ability to communicate effectively with executives, physicians, directors, managers, and staff

• Demonstrates excellent organizational skills

• Demonstrates ability to interact with all levels of staff and management, and ability to set priorities and mange multiple demands effectively

• Clearly and effectively communicates on the telephone, in person, and in memoranda and effectively presents materials and findings to appropriate audiences

Primary Customer Served (Age Specific Criteria):
This position is not a patient care position, and as such, this section does not apply.

Patient Privacy (HIPAA Compliance):
Employees in this position have access to protected health information. The protected health information a person in this position can access includes demographics, date of service, insurance/billing, medical record summary information, and all other information that may be contained in patient records. This position requires patient health information to perform the functions outlined as part of this position description.

Duties And Responsibilities:

Essential (Not Modifiable)

Accreditation:

• Works with the Director, Quality Management Services to develop appropriate data collection and assessment tools to support compliance activities in response to dynamic regulatory requirements

• Oversees and leads the Continuous Readiness team. Develops and timely submits the Periodic Performance Review, and supports Chapter leaders in implementation of new and revised standards

• Acts as a trusted resource and guidance leader for Federal, State and local regulatory agencies (e.g. CMS, OSHPD, etc.) and accrediting agency requirements to ensure compliance

• Manages ongoing tracer activities in collaboration with other departments using a standardized set of tools and methodologies

• Provides timely feedback about findings and staff performance to the appropriate manager or designee of the areas in which tracers are conducted. Synthesizes data and other information into summary format in a logical and systematic manner to facilitate conclusions and recommendations. Enters and verifies data collected into databases and web-based applications

• Analyzes and reports findings and utilizes tracer tools and process to identify and report system issues and evaluate effectiveness of corrective actions and improvement strategies both as a participant and influencer in continuous improvement activities

• Manages and distributes a Joint Commission scorecard across the organization

• Directly supports the continuous readiness activities in the preparation, organization and maintenance of documents related to project management, meeting agendas and materials, action plans and reports

• Participates in the design and development of Joint Commission related and other regulatory driven education curricula, materials, tools and instructional methodologies

• Interfaces with executives to develop work plans for, and track progress on, The Joint Commission Readiness Plan and aspects of the Operations that pertain to regulatory compliance

• Strives for continuous professional development in maintaining and increasing knowledge and skills related to regulatory requirements

• Liaison to California Department of Public Health Services for all licensing related activities, including but not limited to General Acute Care Hospital surveys, and event investigations.

• Supports content experts in ensuring licensure applications and compliance.

• Develops and monitors operational, capital, and staffing budgets.

• Develops and maintains policies and procedures related to accreditation and regulations.

• Works in cooperation with Community Relations Department to plan/coordinate promotional materials and events related to accreditation.

• Manages and maintains regulatory status of House-wide Administrative and Clinical policies and procedures and assists with approval process of departmental policies and procedures.

• Manages and maintains regulatory status of hospital forms.

Secondary (Modifiable)

• Other duties as assigned

Accommodation:

Qualified applicants with disabilities may request reasonable accommodation during the application process by contacting Human Resources at 415-925-7040 or [email protected].

 

C.A.R.E.S. Standards:

MarinHealth seeks candidates ready to model our C.A.R.E.S. standards—Communication, Accountability, Respect, Excellence, Safety—which foster a healing, trust-based environment for patients and colleagues.

 

Health & Immunizations:

To protect employees, patients, and our community, MarinHealth requires measles, mumps, varicella, and annual influenza immunizations as a condition of employment (and annually thereafter). COVID-19 vaccination/booster remains strongly recommended. Medical or religious exemptions will be considered consistent with applicable law.

 

Compensation:

The posted pay range complies with applicable law and reflects what we reasonably expect to pay for this role. Individual pay is set by skills, experience, qualifications, and internal/market equity, consistent with MarinHealth’s compensation philosophy. Positions covered by collective bargaining agreements are governed by those agreements.

 

Equal Employment:

All qualified applicants will receive consideration for employment without regard to race, color, religion, national origin, sexual orientation, gender identity, protected veteran status or disability status, and any other classifications protected by federal, state, and local laws.