The Manager of Accreditation and Regulatory Compliance is responsible for performing a wide variety of duties in leading and managing all aspects of accreditation and regulatory compliance across the Health System including standards and expectations from the Joint Commission (TJC), CMS, Department of Health, and other related accreditation and regulatory requirements. This position ensures that all portions of the organization maintain continuous compliance with state and federal regulatory and accrediting agencies standards.

RESPONSIBILITIES:

• Develops and manages approach to a proactive, systematic, objective, and continuous process of self-assessment, compliance, and readiness with all TJC - CMS - DOH and related regulatory and accreditation standards in partnership with key stakeholders across the system.
• Manages complex improvement projects potentially crossing multiple distinct clinical and nonclinical areas.
• Provides consultation to leadership and key stakeholder groups and ad hoc teams on accreditation and other regulatory-related performance improvement activities.
• Develops a process that includes ongoing mock survey audits, inspection audits, and safety tracers for compliance with TJC and CMS standards.
• Develops and implements strategies to ensure continuous readiness for external unannounced surveys and directly manages those surveys and their post survey activity when they occur.
• Advises senior management and executive leadership of potential vulnerabilities and recommends improvement or corrective actions to maintain compliance.
• Acts as the subject matter expert on regulations and accreditation standards and maintains on-going knowledge of hot topics in the industry related to safety and accreditation.
• Assists with the investigation of reportable safety events, makes recommendations to leadership regarding findings, submits formal reports to regulatory bodies when appropriate.
• Coordinates and facilitates performance improvement activities such as root cause analysis and corrective action planning.
• Designs and manages methods for collecting organization wide regulatory compliance and performance improvement data for reporting.
• Works with leaders to ensure continuous improvement in metrics is being obtained.
• Assists leadership in identifying and maintaining needed accreditation-required policies and procedures.
• Collaborates with key stakeholders to ensure accreditation-related documentation practices, training, and education requirements for providers and staff are met or exceeded.
• Prepares analyses and reports, to communicate progress, recommendations etc. to Bon Secours Executive Leadership and the Board of Directors.
• Manages the corrective action and performance improvement of significant safety events and survey activity.
• Performs other duties as assigned.

QUALIFICATIONS / REQUIREMENTS:

Clinical background required, with 3-5 years' experience in acute care settings. Previous experience with TJC and Department of Health survey activity preferred.

EDUCATION:

Bachelor's degree required.

OTHER:

Travel will be required to all three acute care hospitals as business needs dictate. Proficiency with Microsoft Office Products (word, PowerPoint, excel).

If applicable, the individual performing this job may reasonably anticipate coming into contact with human blood and other potentially infectious materials. Individuals in this position are required to exercise universal precautions, use personal protective equipment and devices, and learn the policies concerning infection control.

About Us:

Good Samaritan Hospital

Good Samaritan Hospital in Suffern, NY, is a 286-bed hospital providing emergency, medical, surgical, obstetrical/gynecological and acute-care services to residents of Rockland and southern Orange counties in New York; and northern Bergen County, NJ. The hospital is home to a recognized cardiovascular program, comprehensive cancer-treatment services, the area's leading Wound and Hyperbaric Institute and outstanding maternal/child services that includes a Children's Diagnostic Center. Good Samaritan Hospital also provides social, psychiatric and substance-abuse services and its certified home-care agency supports residents of the Hudson Valley and beyond.