Updated: Apr 3, 2024
Location: Orange
Job Type:
Department: Risk Management
UC Title: REGL AND CMPLNC HC SPEC 5
Position Number: 41080617
Reports to: Director
Working Title: Regulatory & Cmplnce HC Spec 5
Cost Center: Risk Management (428612)
Bargaining Unit: No Bargaining Unit
FLSA: Exempt
Date Created: 4/02/2024
Job Code: 006530
Hours: 40
Shift: Not Applicable
FTE: 1
Position Summary:
Reporting to the Director, Risk & Regulatory Affairs, the Accreditation & Regulatory Affairs Manager directs and coordinates accreditation, policy and regulatory affairs initiatives for UC Irvine Health; serves as the organizational liaison with The Joint Commission (TJC), California Department of Public Health (CDPH), and other pertinent regulatory agencies. The incumbent performs a variety of duties including development of strategies for compliance, analysis of accreditation standards, regulations, and policies impacting UC Irvine Health and operations; and collaborates with hospital departments, services, clinics, and business partners in understanding and complying with accreditation standards, regulatory agencies, and hospital policies.
Total Compensation
In addition to the salary range listed below, we offer a wealth of benefits to make working at UCI even more rewarding. These benefits may include medical insurance, sick and vacation time, retirement savings plans, and access to a number of discounts and perks. Please utilize the links listed here to learn more about our:
Compensation practices (https://www.hr.uci.edu/partnership/totalrewards/compensation.php) and
Benefits (https://careersucirvine.ttcportals.com/pages/benefits).
Salary Range:
Annual Rate Minimum $138,800.00 Midpoint $208,300.00 Maximum $277,800.00
Responsibilities:
Maintains records of compliance deficiencies, corrective action plans, change status, audits and reporting of monitoring to proper channels
Performs gap analyses to identify areas of vulnerability in compliance with standards and makes recommendations to Medical Center Joint Commission Function Leaders and/or Senior Management
Develops and monitors regulatory and accreditation corrective action plans to eliminate or minimize risk of non-compliance or incompletion; assesses, tracks and monitors corrective action plans for evidence of sustainability
Develops communication plans to support regulatory compliance priorities and initiatives
Monitors The Joint Commission (TJC) Sentinel Event alerts and determines what actions are required / appropriate for the organization
Participates in weekly environment of care rounds and auditing activities with leaders of the organization in patient care and ancillary services areas to determine compliance and identification of potential regulatory/accreditation risks; follows up with action items as appropriate.
Keeps informed of changes to regulatory and accreditation requirements to ensure organizational compliance. Functions as an internal expert / resource for interpretation of regulations and accreditation requirements
Establishes regulatory priorities and budget
Accurately identifies salient issues associated with specific standards, clinical documentation, policies and procedures and communicates these to appropriate stakeholders within the organization
Analyzes compliance with accreditation standards, licensing and regulatory requirements, and hospital policies through the evaluation of information
Serves as an internal consultant to clinical (e.g. Nursing, Radiology, Respiratory Therapy) and non-clinical departments (e.g. Facilities, EH&S, Infection Prevention) regarding TJC and CMS interpretation and implementation strategies for compliance
Monitors compliance and designs/tracks and reports accreditation, licensing, and regulatory performance results to leadership, making recommendations for adjustments as appropriate
Develops the Health System readiness program and the necessary tools for the assessment of such program
Educates staff on new or revised accreditation, licensing and regulatory requirements/standards. Develops, coordinates and participates in the implementation of educational and training programs to ensure survey readiness at all levels of personnel
Participates in root cause analyses of sentinel events, as appropriate, ensuring adherence to TJC format; relies on experience and expertise to dig deep into issues and find answers
Required Qualifications:
Demonstrated ability to problem solve, think critically and creatively, and provide leadership through a consultative role
Strong knowledge of CMS Conditions of Participation, Federal and State (Titles 22 & 24) regulations, and The Joint Commission accreditation standards. experience in a key role in CMS and Joint Commission surveys
Bachelor's Degree in a health-related field, RN, or equivalent experience in Quality & Patient Safety
Minimum of five years’ experience in a quality or regulatory compliance role within a hospital or health care organization
Ability to manage numerous diverse projects simultaneously through effective priority setting
Must have excellent presentation and computer skills
Effective written and verbal communication skills; ability to communicate with customers/staff with diverse educational backgrounds
Must be able to work flexible hours and locations based on the organization's needs
Preferred Qualifications:
Master's Degree in health related field
Recent experience leading a CMS or Joint Commission survey
Current RN License
Conditions of Employment:
The University of California, Irvine (UCI) seeks to provide a safe and healthy environment for the entire UCI community. As part of this commitment, all applicants who accept an offer of employment must comply with the following conditions of employment:
- Background Check and Live Scan
- Legal Right to Work in the United States
- Vaccination Policies
- Smoking and Tobacco Policy
- Drug Free Environment
The following additional conditions may apply, some of which are dependent upon business unit or job specific requirements.
- California Child Abuse and Neglect Reporting Act
- E-Verify
- Pre-Placement Health Evaluation
Details of each policy may be reviewed by visiting the following page: https://hr.uci.edu/new-hire/conditions-of-employment.php
Closing Statement:
The University of California, Irvine is an Equal Opportunity/Affirmative Action Employer advancing inclusive excellence. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, age, protected veteran status, or other protected categories covered by the UC nondiscrimination policy.
We are committed to attracting and retaining a diverse workforce along with honoring unique experiences, perspectives, and identities. Together, our community strives to create and maintain working and learning environments that are inclusive, equitable and welcoming.
UCI provides reasonable accommodations for applicants with disabilities upon request. For more information, please contact UCI’s Employee Experience Center (EEC) at [email protected] or at (949) 824-0500, Monday – Friday from 8:30 a.m. – 5:00 p.m.
