Regulatory and Accreditation Manager

Mgr Accreditation & Regulatory

Job Code: MG1372

ABOUT US

We are welcoming a new era in healthcare where achieving good health is just the beginning. At UVA Health Northern VA & Culpeper, we believe in caring for the whole person by getting to know - and making connections with - our patients. By combining the talent and expertise of our people, the breadth of capabilities across our system, and our commitment to helping our communities get better and stay healthy, we are improving the patient experience.

As a UVA Health Northern VA & Culpeper team member, you will have a voice in patient care decisions, support the most advanced medical technologies and feel a strong sense of satisfaction from making a difference in people's lives every day.

JOB TYPE

Classification: Exempt

Supervises Positions:

JOB SUMMARY

The Manager Accreditation and Regulatory I is a registered nurse or health care professional with a comparable clinical degree who assumes responsibility for managing: (1) Accreditation, certification and regulatory compliance and survey activities in conjunction with the corporate Accreditation and Regulatory team (AR) and the Sr. Director of Accreditation Regulatory through maintaining continuous readiness structures and key relationships with the leaders in the assigned facility(s) and/or corporate functional process. (2) Processes that assure local, regional/market and corporate standards that dictate care, patient safety and clinical practices as outlined in policies, procedures, forms, and other documents. Each manager position will have individual assignments with facility and/or function-based roles. (1) Facility-based assignment examples: Ambulatory/Provider-based Practices, MedQuest, Ambulatory Surgical Centers, Acute Care Hospitals. (2) Corporate regulatory function assignment examples: Policies and Procedures ndash; Corporate, Disease Specific Certification, Corporate Connectivity - Education and Metrics, Clinical Forms ndash; Corporate, All UVA Surgical Services Specialty, All UVA Radiological Services Specialty, All Behavioral Health Emergency Departments Specialty, PJC - Event Regulatory Review Specialty, New Facility Integration ndash; as assigned. Others as assigned.

QUALIFICATIONS

Education: 4 Year/Bachelor's Degree required - BSN or comparable clinical degree. Graduate Degree preferred.

Experience: Registered Nurse or Clinical Professional with minimum of 5 years clinical experience required. 2 years of applicable Accreditation and Regulatory experience with 2 years of leadership experience preferred. Refer to the Life Support Training Policy for additional details.

Licensure: Current RN licensure in applicable state or comparable clinical degree required.

Additional Skills/Requirements Required: Excellent verbal communications skills. Displays excellent computer, writing and editing skills. Demonstrates the ability to write clearly and concisely, and in a manner that diminishes risk and provides a clear concise guide for best practices. Ability to work collaboratively with other health care professionals and manufacture change without authority. Ability to organize and determine work priorities and delegate appropriately. Consulting, team-oriented, supportive, and cooperative attitude. Utilizes appropriate decision-making strategies: authoritative, consultative, consensus. Exhibits self-direction, independent practice, and excellent time management skills. Able to continuously reprioritize, demonstrate flexibility, and process multiple issues simultaneously. Creates an environment that supports and respects diversity, modeling behavior and language that is inclusive, and nurturing an environment where it is acceptable to discuss differences and issues of diversity. Has a questioning attitude.

Additional Skills/Requirements Preferred: N/A

Competencies

• Analysis: Analyzes processes and creates deliverables to provide information and recommendations for improvements.
• Breaks down problems and issues into sub-components and assesses the costs, benefits, and risks of various options.
• Is able to select and recommend the best solution based on a thorough examination of all considerations.
• Is able to explain and justify actions in a systematic and logical fashion.
• Communication: Shares and receives information using clear oral, written, and interpersonal communication skills.
• Demonstrates effective written and oral communication skills.
• Actively listens, provides constructive feedback, and demonstrates respect for differing views.
• Tailors communications to diverse audiences.
• Quality Improvement: Demonstrates involvement in the unit's annual and/or periodic assessment efforts, including efforts to improve the quality services.
• Understands the value of innovation and quality improvement.
• Improves processes and practices by identifying inefficiencies and redundancies.
• Demonstrates efficiency and quality in one's own work.
• Customer Service: Builds relationships and maintains strategic partnerships with key internal and external stakeholders.
• Understands the importance of quality service.
• Is able to adjust and adapt service delivery to diverse customer needs and sensitivities.
• Frequently suggests and implements changes to improve the quality of service.
• Financial Management: Manages tasks and resources within the department to achieve quality and meet budget requirements.
• Ensures that financial and material resources are used effectively and efficiently.
• Leverages resources to maximize utility and return on investment (ROI).
• Implements measures to minimize theft, damage, or equipment breakdown.

The incumbent may be asked to perform additional duties as assigned.

PHYSICAL DEMANDS

Physical Demand Code: Medium to Heavy Physical Demand: The job requires constant standing, frequently walking, and bending/stooping. Proficient communicative, auditory, and visual skills. Attention to detail and ability to write legibly. Ability to lift/push/pull 100 lbs. For any weight over 35 lbs., use Safe Handling Equipment. This job description may not include all assigned duties, responsibilities, or aspects of the job described. It may be amended at any time at the sole discretion of UVA Community Health.

OTHER

• May require the use of safety equipment, such as HEPA mask, for infection prevention: Yes
• On call responsibilities as directed: No
• Ability to travel between campus buildings, remote facilities, and out of town as needed: Yes