Director, Licensure and Accreditation Job in Los Angeles, California US
Director, Licensure and Accreditation
Manages, facilitates and supports activities relating to licensing, accrediting, and regulatory within the Service Area, including preparation for, compliance with, and follow up for all surveys such as CALS, MCQA, CAP, DHS, OSHA, etc. Collaborates with administrators, managers, chiefs of service and other physician leaders to assist with and coordinate all regulatory functions/efforts. Ensures that all areas of vulnerability with regard to accreditation and licensing are identified. Works with individuals and/or teams to develop quality action plans for improvement. Essential Functions: - Serves as the primary contact for all regulatory agencies: Provides consultative services to all KFH/P and SCPMG departments and services regarding intent of regulations and means to maintain compliance. - Keeps abreast of changes in legislation and requirements related to regulatory accreditation and licensing issues. May maintain the Service Area Administrative Policy Manual. - Assures continuity and consistency in compliance with regulatory issues across the organization by evaluating the impact of specific issues. Collaborates with appropriate departments to develop and implement corrective action to minimize negative impact and maximize learning. - Identifies key accreditation, regulation and licensing issues and defines areas for improvement. - Relays internal/external communication of information related to accreditation, regulation and licensing. Prepares for surveys and inspections for all regulatory agencies. - Maintains relationship with representatives of regulatory agencies. - Collaborates and coordinates with departments on any implementation and evaluation of legislation affecting the Service Area. - Provides overall staff support to the Accreditation and Licensing Committee such as to coordinate activities and agenda, to manage meeting minutes and action plans, and to provide research analysis and recommendations for issues. - Develops and monitors annual budgets for all areas of responsibility. Qualifications: Basic Qualifications: - Bachelor's degree, or equivalent experience in Health Care Administration, Public Health, nursing or other related field. Master's degree preferred. Clinical experience and clinical operations management preferred. - Significant experience in health care (usually 5 years). - Working knowledge of federal and state laws and regulations such as JCAHO, NCQA, Knox-Keene Act, Federal HMO Act, Health Care Financing Organization (HCFA), CMRI, Public Employees Medical and Hospital Act, applicable MediCal and Medicare regulations and rulings, and California Medical Review. - Demonstrated experience in adult education and motivational theories, statistical analysis and quality management process. - Excellent oral and written communication skills. Preferred Qualifications: - Master's in Health Care Administration or related field. - Knowledge of Title 22 requirements, knowledge of V Surgery Electronic Surveillance Program, strong PC skills. - Experience inleading change. - Experience in staff education and strong communication and presentation skills.