Accreditation, Regulatory, and Licensing Specialist IV (KFHP/H)

Job Summary: Conducts regulatory audits and surveys by independently reporting and keeping current on regulatory requirements in preparation for surveys. Organizes, coordinates, and conducts facilitation of on-site visits and evaluations. Performs site visits in accordance with criteria to ensure survey readiness. Ensures completion of surveys, independently. Conducts routine audits and mock surveys to aid in preparedness, tracking, trending, and facilitation of corrective action plans. Collaborates with others to complete annual reporting. Ensures licensing and accreditation by reviewing requirements for new, expanding, and existing facilities/services in relation to relevant accrediting standards, evaluating relevant risk and impact independently. Consults with departments to ensure certification and conducts moderately complex gap analyses. Serves as the subject matter expert by maintaining and facilitating awareness of internal policies and consulting on the interpretation and interaction of current policies, and how they interact with the current climate, and potential changes to regulations and legislation. Develops moderately complex content and delivers education programs to align policies with regulatory requirements. Conducts data management by entering and analyzing practitioner/provider data. Independently drafts and provides consultative expertise on implementation of action plans for timely implementation.
Essential Responsibilities:

• Promotes learning in others by proactively providing and/or developing information, resources, advice, and expertise with coworkers and members; builds relationships with cross-functional/external stakeholders and customers. Listens to, seeks, and addresses performance feedback; proactively provides actionable feedback to others and to managers. Pursues self-development; creates and executes plans to capitalize on strengths and develop weaknesses; leads by influencing others through technical explanations and examples and provides options and recommendations. Adopts new responsibilities; adapts to and learns from change, challenges, and feedback; demonstrates flexibility in approaches to work; champions change and helps others adapt to new tasks and processes. Facilitates team collaboration to support a business outcome.
• Completes work assignments autonomously and supports business-specific projects by applying expertise in subject area and business knowledge to generate creative solutions; encourages team members to adapt to and follow all procedures and policies. Collaborates cross-functionally and/or externally to achieve effective business decisions; provides recommendations and solves complex problems; escalates high-priority issues or risks, as appropriate; monitors progress and results. Supports the development of work plans to meet business priorities and deadlines; identifies resources to accomplish priorities and deadlines. Identifies, speaks up, and capitalizes on improvement opportunities across teams; uses influence to guide others and engages stakeholders to achieve appropriate solutions.
• Serves as the subject matter expert for regulations within assigned departments by: maintaining awareness of current internal policies and external regulations, and legislation; providing consultation on the interpretation, interaction, and implementation of current policies, regulations, and legislation, with guidance from senior colleagues; attending committees and actively contributing consultative guidance on the enforcement of regulations and auditing processes; developing moderately complex content and delivering educational programs to align organizational policies and procedures with regulatory requirements; and identifying and escalating issues and seeking input from leadership to resolve.
• Conducts data management and reporting support by: entering practitioner/provider data into the appropriate database; and entering, analyzing, and independently drafting action plans/recommendations required data into appropriate databases and providing consultative expertise during implementation of action plans.
• Ensures licensing and accreditation by: independently reviewing requirements for new, existing, and expanding facilities/services to aid in achievement of compliance with state, federal, and accrediting standards; consulting with other departments to ensure certification for moderately complex cases; and independently conducting a nuanced gap analysis and mentoring others to identify services renewals and planning to ensure services are compliant.
• Conducts regulatory audits and surveys by: independently reporting moderately complex and keeping current on regulatory requirements in preparation for surveys (e.g., NCQA, Joint Commission, AAAHC); coordinating with departments and external representatives to organize and support on-site visits and evaluations; independently conducting, reviewing, evaluating upon site visit criteria, and performing site visits as appropriate to ensure survey readiness delivering requested audit documentation, information, and reports; coordinating with stakeholders within designated department to ensure the completion of required auditing surveys, focusing on high vulnerability areas; aiding in the facilitation of educational forums and conducting standard routine audits and mock surveys within departments to ensure auditing and survey preparedness. tracking, trending, and facilitating the development of corrective action plans (CAP) as necessary in collaboration with applicable departments to assure site visit compliance; and collaborating with other departments (e.g., Revenue Cycle), gathering documents and data to support the timely completion of the annual state/federal/regulatory body reporting as required.

Minimum Qualifications:

• Minimum one (1) year of experience in a leadership role with or without direct reports.
• Minimum two (2) years of experience with databases and spreadsheets.
• Bachelors degree in Business Administration, Health Care Administration, Nursing, Public Health, or related field AND minimum five (5) years of experience in health care operations, quality, risk management, hospital environment, or a directly related field OR minimum eight (8) years of experience in health care operations, quality, risk management, hospital environment, or a directly related field.