This position provides management and expertise in the areas of accreditation and regulatory compliance, as it relates to colleagues, medical staff, and inpatient and outpatient services for Saint Agnes Medical Center (SAMC). This role is responsible for planning, developing, implementing and evaluating the overall Saint Agnes Continuous Regulatory Readiness program and survey activity. Position oversees tracking and supporting regulatory survey processes throughout Saint Agnes, including Triennial Joint Commission accreditation and specialty accreditation (initial or reverification). Fosters and supports a culture of continuous improvement and coordinates the systematic implementation of effective practices designed to reduce error and improve patient outcomes cohesively across the system. Work collaboratively with leadership, management, medical staff, and interdisciplinary staff across the entire organization. Provides day-to-day oversight of the programs including personnel management, deployment of resources, project management, evaluation of processes, analysis of data, and continuous regulatory readiness. The incumbent will leverage clinical information technology, process design, change management and evidence-based leading practices to support optimal quality outcomes, improve data-driven performance and promote ongoing survey readiness and compliance with accreditation regulations and standards. This position also supports specific initiatives related to external certification or recognition as reflected in the organization's strategic quality and safety priorities.
REQUIREMENTS
1.Experience in decision-making, leadership and in-depth knowledge, safety, is preferred
2.Must possess a comprehensive knowledge of regulatory readiness, standards interpretation, and project management, management, and training and development in regulatory preparations
3.Bachelor’s degree in Health Administration, Nursing or a related field is required with five (5) years of quality or regulatory experience or an equivalent combination of education and experience. Master's degree is preferred.
4.Current licensure as a Registered Nurse (RN) or other clinical licensure in the State of California is required.
5.Experience in interpreting and advising regarding regulatory and accreditation standards.
6.Strong verbal and written communication skills are required. Ability to present information in a confident, clear, concise, and articulate manner is required. 7.Proficiency in using Microsoft Office products, including Excel and PowerPoint, and various other computer software products is required.
Pay Range ($114,982– $172,515)
Our Commitment
Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.
Skills Required
- Bachelor's degree in Health Administration, Nursing or a related field
- Five years of quality or regulatory experience or an equivalent combination of education and experience
- Current licensure as a Registered Nurse (RN) in California
- Experience in interpreting and advising regarding regulatory and accreditation standards
- Strong verbal and written communication skills
- Proficiency in using Microsoft Office products
What We Do
Trinity Health is one of the largest not-for-profit, Catholic health care systems in the nation. It is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians caring for diverse communities across 25 states. Nationally recognized for care and experience, the Trinity Health system includes 88 hospitals, 131 continuing care locations, the second largest PACE program in the country, 125 urgent care locations and many other health and well-being services. Based in Livonia, Michigan, its annual operating revenue is $20.2 billion with $1.2 billion returned to its communities in the form of charity care and other community benefit programs.
