Company: Alameda Health System
Posted on: November 19, 2021
Summary Role Overview Come join Alameda Health System (AHS) as
our newest Accreditation Manager! As an Accreditation Manager with
AHS you will plan , coordinate and monitor compliance with federal,
state and local regulations. You will partner with leaders
throughout the system to manage accreditation activities necessary
for maintaining required accreditation. You will champion and
manage the requirements for certifications and licensure for a
variety of organizations, such as Joint Commission (JC), California
Department of Public Health (CDPH), CMS, OSHPD, CDPH Lab Field
Services, CDPH Radiologic Health Branch. This is a great
opportunity to apply your knowledge in all things accreditation,
and to make a difference in your community! Responsibilities NOTE :
The following are the duties performed by employees in this
classification, however, employees may perform other related duties
at an equivalent level. Not all duties listed are necessarily
performed by each individual in theclassification.
- Identifies growth and areas of opportunity to enhance
Regulatory Affairs and AHS initiatives.
- Identifies regulatory vulnerabilities and determines escalation
level if necessary.
- Provides guidance on Joint Commission standards interpretation
and other regulatory requirements as they apply to organizational
- Actively coordinates the organization--s readiness rounds
program and is primarily responsible for the development,
communication, implementation and tracking of action plans
necessary to close identified gaps in care or compliance with The
Joint Commission (TJC) standards and Centers for Medicare and
Medicaid Services (CMS) and Title 22 regulations.
- Assists in all accreditation and regulatory activities,
including surveys, survey preparation and readiness
- Develops comprehensive accreditation work plans by establishing
deliverables, accountabilities, and timelines.
- Serves as contact and point person for Joint Commission
accreditation manuals, standards-related publications and
newsletters and educational materials; distributes pertinent
- Maintains and implements department unannounced survey
- Manages onsite accreditation and regulatory surveys; supports
command center activities.
- Manages communications, agendas, and logistics for onsite
- Finalizes corrective action responses to The Joint Commission
and other regulatory agencies for survey and for-cause and
- Prepares the Joint Commission applications for accreditation,
updates information accurately.
- Performs other duties as assigned. Qualifications Any
combination of education and experience that would likely provide
the required knowledge, skills and abilities as well as possession
of any required licenses or certifications is qualifying. Required
Education : Bachelor--s degree in nursing or healthcare related
field. Preferred Education : Master--s degree in a healthcare
related field. Required Experience : Five years of hospital
operations or patient care experience; two years in
accreditation/licensing/regulatory compliance/ quality/performance
improvement/patient safety in healthcare; experience applying
quality assurance/performance improvement (QAPI) and customer
service approaches; experience with Midas, Epic / Electronic Health
Record (EHR), County Health Systems, OSHPD.. Preferred
Licenses/Certifications : Certified as a Professional Healthcare
Quality (CPHQ) or Certified as a Joint Commission Professional
(CJCP); LEAN/Six Sigma Certification.
Admin, Business & Clinical Support
Keywords: Alameda Health System, Oakland , Accreditation Manager, Executive , Oakland, California
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