Responsible for oversight of system regulatory and accreditation programs including the coordination of all relevant activities as per the requirements of state statutes, CMS and the Joint Commission. The Program Manager of Regulatory and Accreditation facilitates regulatory survey continual readiness program planning to support CHRISTUS Health mission, values and business objectives.
The Program Manager of Regulatory and Accreditation is responsible for supporting regulatory readiness including maintenance of a system wide calendar of all accreditation, licensure, and other regulatory survey activities. Functions as a key point of contact for internal partners and external agencies on accreditation and licensure related questions. Facilitates the development of action plans to correct non-compliance with standards. Develops strategies for compliance, analysis of accreditation standards, regulations, and policies impacting CHRISTUS facilities. Prepares reports to track performance of the system in relation to accreditation or other regulatory requirements.
Supports optimal system compliance with accreditation and regulatory requirements from a variety of regulatory agencies.
Accurately identifies issues and trends associated with specific standards, clinical documentation, policies, and procedures and communicates these to appropriate persons within the organization.
Analyzes compliance with accreditation standards, regulatory rules and hospital policies through the evaluation of information from continual readiness activities throughout the regions.
Monitors compliance with accreditation and uses reports to track current compliance and status of strategies for improving compliance and internal performance. Provides regular feedback to system leadership.
Analyzes policy for internal consistency and compliance with accreditation and regulatory requirements. Facilitates and collaborates with others in the development of new policies for the system.
Standard: Demonstrates current knowledge of regulatory, accreditation, and policy requirements.
Acts as a consultant to regions and leads the development of compliance strategies for support of the regional processes.
Facilitates and supports special projects designed to assess or improve compliance with standards and system goals.
Collaborates with others to facilitate easy to understand, accurate, and timely reports and monitoring tools for evaluation of compliance.
Demonstrates effective collaboration and coordination skills while working with a variety of departments and positions to accomplish goals of regional support.
Collaborates with various disciplines, departments, services and business partners to assess compliance and develop compliance strategies for use in the regions.
Bachelor's degree in a healthcare related field is required
Minimum of three (3) years of current experience in regulatory or accreditation is required
Certified Joint Commission Profession (CJCP) required or must obtain within one (1) year of hire is required
Must possess excellent communication, organizational and human relation skills.
Must have flexibility in dealing with changing job demands.
Works effectively in multi-disciplinary teams, leading and facilitating teams to move the organization to new areas of excellence.
Must have the ability to maintain confidentiality of information.
Proven ability to function independently.
Must have strong organizational, analytical and computer technology skills.
CHRISTUS HEALTH is an international Catholic, faith-based, not-for-profit health system comprised of almost more than 600 services and facilities, including more than 60 hospitals and long-term care facilities, 350 clinics and outpatient centers, and dozens of other health ministries and ventures. CHRISTUS operates in 6 U.S. states, Colombia, Chile and 6 states in Mexico. To support our health care ministry, CHRISTUS Health employs approximately 45,000 Associates and has more than 15,000 physicians on medical staffs who provide care and support for patients. CHRISTUS Health is listed among the top ten largest Catholic health systems in the United States.