Manager - Accreditation and Regulatory Affairs

Position Objective:

Under the direction of the VP, Quality & Patient Safety, the Manager develops and implements organizational initiatives to support Luminis Health (LH) accreditation and regulatory continuous readiness. The Manager will work with the LH acute care hospitals, clinicians, clinical support and other health system leaders on the continuous readiness program and ongoing  1) Standard interpretation, 2) Standard compliance, 3) Education and communication about regulatory affairs, and 4) Survey operations. The Manager  emphasizes quality and patient safety at the forefront of regulatory compliance and oversees the day-to-day department program operations and workflow. The Manager directly supervises Accreditation and Regulatory Specialists and is expect to split time on-site at both of the acute care hospitals

Essential Job Duties:

1.    Proactively leads the ongoing evaluation, planning and support of the LH continuous readiness infrastructure and processes to ensure accreditation by deemed status accrediting organizations such as The Joint Commission, CMS, Office of Healthcare Quality, as well as other regulatory accreditationgoaimobile