1+ months

Director, Office of Licensure, Accreditation & Regulation (Nursing)

Cedars-Sinai
Los Angeles, CA 90006
The Director, Office of Licensure, Accreditation and Regulation directs the Medical Center's operations and activities to comply with licensure, accreditation, and regulation requirements for all heath care sites and services across the continuum including, but not limited to: ambulatory services, hospital services, contract services in collaboration with medical staff, Quality Services, Clinical Operation Teams, Corporate Compliance and Environmental Safety. He/She translates various accrediting, regulatory and licensing agency requirements into action plans to achieve positive survey/audit reviews and renewed licenses; implements systems to effectively monitor compliance to standards and to implement new processes to meet new requirements. Directs the Medical Center's operations and activities to comply with all licensing and accreditation standards and requirements, ensuring consistency with organizational goals and priorities. Works close with medical staff, executive management, department directors and managers to ensure that principles of confidentiality and responsibility are adhered to. Determines strategy for changing existing process to meet regulatory requirements and translating external demands into program goals. **Responsibilities** + Develops tools that assist in determining exposure to regulatory and accreditation risks. Identifies opportunities to manage and mitigate those risks. Provides guidance and oversight to client and related business unit audit functions to ensure ongoing regulatory and accreditation compliance, and assists client to establish ongoing monitoring and corrective action plans relating to regulatory and accreditation compliance. + Leads clinical compliance projects, and mentors clinical compliance staff. Accomplishes assigned project objectives by direct work performance, including document review, interviews, research, analysis, completion of worksheets, and development of findings/deficiencies as applicable. + Determines strategy for changing existing processes to meet regulatory requirements and translating external demands into program goals. + Interprets and assists in planning responses to new or changing regulations or standards. Collaborates with external regulators to develop standards that promote high quality patient care and serves. + Serves as liaison to professional organizations and licensing/regulatory agencies. Serves as the point of contact for clients as it relates to clinical compliance, including coordinating and collaborating with regulatory bodies and organizational leaders to ensure compliance with regulatory, accrediting, quality of care, and service requirements. + Develops methods for compiling information and record keeping related to quality improvement and compliance monitoring activities and maintains relevant records. Provides guidance and oversight to client and related business unit audit functions to ensure ongoing regulatory and accreditation compliance, and assists client to establish ongoing monitoring and corrective action plans relating to regulatory and accreditation compliance. + Makes recommendations to clients business unit partners for improvements or remediation to risk management, regulatory, and accreditation compliance programs. **Qualifications** + Masters Degree in Nursing or healthcare administration profession which requires a professional license or national certification to practice, or in business administration, public health, health administration, or related field is preferred. + Bachelors Degree in Nursing with a valid California RN License required. + A minimum of five years clinical experience required. + A minimum of five years administrative experience required. + Working knowledge of healthcare regulatory environment, Medicare/Medicaid, HIPAA. Fraud, waste and abuse rules emphasis on CA regulations. Nursing Practice Act, The Joint Commission and other state and local regulatory requirements strongly preferred. + Strong interpersonal and communication skills. And has full command (verbal and written) of the English language. + Knowledgeable and proficient in the use of health care technology within specialty area required. + High level of proficiency using Microsoft Windows and other Microsoft Office software: MS Excel, Outlook, Powerpoint Word, required. + Healthcare Compliance (CHC), Professional in Patient Safety (CPPS), Certified Professional in Healthcare Quality (CPHQ), Certified Joint Commission Professional (CJCP), Healthcare Accreditation Certified Professional (HACP) strongly preferred. Cedars-Sinai is an EEO employer. Cedars-Sinai does not unlawfully discriminate on the basis of the race, religion, color, national origin, citizenship, ancestry, physical or mental disability, legally protected medical condition (cancer-related or genetic characteristics or any genetic information), marital status, sex, gender, sexual orientation, gender identity, gender expression, pregnancy, age (40 or older), military and/or veteran status or any other basis protected by federal or state law.

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Posted: 2019-06-10 Expires: 2020-07-08

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Director, Office of Licensure, Accreditation & Regulation (Nursing)

Cedars-Sinai
Los Angeles, CA 90006

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