Company: Alameda Health System
Posted on: January 15, 2022
Come join Alameda Health System (AHS) as our newest Accreditation
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
This is a great opportunity to apply your knowledge in all things
accreditation, and to make a difference in your community!
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 the
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 assessments.
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 plans.
Manages onsite accreditation and regulatory surveys; supports
command center activities.
Manages communications, agendas, and logistics for onsite survey
Finalizes corrective action responses to The Joint Commission and
other regulatory agencies for survey and for-cause and compliant
Prepares the Joint Commission applications for accreditation,
updates information accurately.
Performs other duties as assigned.
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
Required Education: Bachelor's degree in nursing or healthcare
Preferred Education: Master's degree in a healthcare related
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
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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