Tenet Healthcare has an immediate opening for a Manager, Regulatory and Accreditation to support the enterprise. This position will require a high percentage of nationwide travel - approximately 44 weeks per year.
Manager, Regulatory and Accreditation is responsible for assessing, developing, educating, implementing, monitoring, and leading the Tenet Regulatory and Accreditation activities within the company. This includes preparation and survey readiness. The position develops and implements processes for current safe practices in Tenet. The Manager, Regulatory and Accreditation work closely with other corporate departments, groups, and facilities for collaboration and synergy around identified priorities.
Develops, educates, implements, monitors, and leads, Tenet, regulatory requirements and accreditation standards, goals and targets through collaboration with corporate departments and the Director Quality Patient Safety (DQPS).
Is a leader for the Clinical Operations Department in the formulation of Tenet regulatory and accreditation related goals and targets.
Employ a servant leadership approach to all work.
Employs a transformational approach rather than transactional.
Assists with the development of the Tenet strategy and tactics for regulatory and accreditation preparation and successful surveys
Tracks progression and sustainment of the Tenet regulatory and accreditation strategy and tactics per standardized reporting process.
Provides input for strategic development, planning and implementation of Tenet Clinical Operations Regulatory and Accreditation activities.
Provides leadership and expertise in methods of preparation and sustainment of regulatory requirements and accreditation standards.
Provides leadership and expertise in methods of performance improvement.
Coordinates and collaborates with Tenet leaders on activities related to the development, implementation, improvement of and adherence to the organizationâ��s policies and procedures covering the scope of regulatory requirements and accreditation standards
Supports Tenetâ��s preparation for surveys (i.e., State, TJC, CMS and others)
Conduct formal facility reviews.
Supports the formulation of responses [plans of correction] from surveyors, electronic communication, or third party payers under the direction and approval of the Tenet Clinical Operations Department as needed.
Prepares reports which displays the results of regulatory and accreditation activities and updates the Tenet regulatory requirements and accreditation standards plans and strategies as needed.
Remains current concerning industry-wide, leading practices and evaluates for implementation in Tenet.
Demonstrates ethical behavior in decision-making, performance of job responsibilities while maintaining confidentiality regarding patient information, quality, performance and peer review information.
Prepares reports and presents to various audiences
Facilitates, supports, and organizes process improvement and provides staff support services to such teams.
Develops Tenet policies and procedures for areas of responsibility.
Develops and uses Tenet methods, tools, and other resources for regulatory and accreditation preparedness and sustainment.
Develops and presents educational material to various audiences based on identified or trending regulatory and accreditation issues.
Minimum education, training and background for the successful candidate include:
Bachelors preferred, with experience in regulatory requirements and accreditation standards, performance improvement as applicable in other related areas of responsibility.
Requires an advanced degree in a health related field (Masters) within five years of relevant facility management experience.
At least 10 years of experience leading a multi-hospital system Regulatory and Accreditation program.
Experience leading interdisciplinary initiatives in process improvement and directly with improving reliability of healthcare delivery at the point of care.
Knowledge of TJC and other regulatory standards.
Knowledge of CMS CoP Conditions of Participation and other federal and state requirements.
Knowledge of principles of quality improvement.
Relevant clinical experience.
Strong organizational skills.
Strong written skills.
Strong presentation skills.
Certified Joint Commission Professional (CJCP) orCertified Professional Healthcare Quality (CPHQ) within twelve months of hire date.
SKILLS, KNOWLEDGE AND ABILITIES:
Experienced with and practiced at performance improvement activities.
Skilled at developing and conducting educational presentations.
Expert at remediating findings when in a facility.
Adept at developing methods, tools, reports, data aggregation and conducting regulatory and operational surveys for Tenet facilities, including the review of regulatory requirements and accreditation standards and Conditions of Participation.
Prepares written reports of clinical and operational survey findings.
Make enhancements to survey standards, tools, forms and processes.
Skilled in developing corrective action plans, provide educational programs, monitor implementation of action plan and other oversight activities through follow-up visits to facilities as needed, and provide guidance on regulatory and accreditation communications as needed.
Expert on regulatory requirements and accreditation standards, preparation activities, and success with surveys.
Knowledgeable in the areas of peer review, risk management, patient safety, infection control prevention and reporting
Proficient at detail oriented work and has ability to work with and analyze complex health care process and outcome data using both qualitative and quantitative techniques.
Polished communicator (written, verbal and presentation skills) with many levels of key stakeholders from the board level to the point of care staff.
Expert on TJC, Centers for Medicaid and Medicare, Quality Improvement Organization (QIO), state requirements and other regulatory standards / processes.
Expert with current trends in quality and other areas of responsibility as applicable.
Expert with working, leading, following, coordinating, and managing activities to driving change within Tenet to achieve strategic initiatives for clinical / operational initiatives related to regulatory accreditation.
Identifies potential or actual regulatory/accreditation risk issues at facilities in the assigned groups that can impact regulatory/accreditation compliance and pose a financial or reputational risk to the facility or company and immediately reports those findings to the Tenet Clincial Operations Department to address the issue.
PRIMARY INFORMATION, TOOLS AND SYSTEMS USED:
PC based Word and Excel spreadsheet programs
Industry publications as they relate to Quality and other areas, as applicable, such as Safety, Risk Management, etc.
Employment practices will not be influenced or affected by an applicantâ��s or employeeâ��s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.
Tenet Healthcare Corporation (NYSE: THC) is a diversified healthcare services company headquartered in Dallas with 112,000 employees. Through an expansive care network that includes United Surgical Partners International, we operate 65 hospitals and approximately 510 other healthcare facilities, including surgical hospitals, ambulatory surgery centers, urgent care and imaging centers and other care sites and clinics. We also operate Conifer Health Solutions, which provides revenue cycle management and value-based care services to hospitals, health systems, physician practices, employers and other clients. Across the Tenet enterprise, we are united by our mission to deliver quality, compassionate care in the communities we serve.