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

About this role

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 evalu

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