Program Lead - Accreditation, Licensing and Regulatory Affairs

Responsible for leading the project activities of assigned program related to regulatory affairs. Coordinates status reports as well as participating on teams and working with project staff and stakeholders to assure that requirements are incorporated within the project design. Assigns work to team members to assure timely completion of project milestones and deliverables as appropriate. Develops policies and procedures as appropriate. Identifies and escalate issues following departmental guidelines. Develops communication to share information with other hospital leaders and departments.

Furthermore, Position is primarily responsible for assisting the Executive Director of Accreditation, Licensure and Regulatory Affairs in maintaining high quality and safe care by ensuring organizational systems and processes comply with the state and federal regulations and other identified standards ex. Joint Commission. Participate and support activities relating to accreditation and regulatory standards for all Hospital sites including preparation for, compliance with, and follow up for all surveys. Be a resource for external departments regarding regulatory matters. Collaborate with program coordinator to demonstrate efficiency within the department.

Minimum Education
Bachelor's Degree (Required)

Minimum Work Experience
3 years Relevant work experience (Required)
1 year Relevant work experience with Masters degree (Preferred)

Functional Accountabilities
Program Liaison

• Lead the program by being the primary point person and designee for Executive Director at meetings.

• Serve as the liaison between CNHS and external stakeholders as needed

• Manage program specific partnerships with various stakeholders including leadership at affiliated institutions.

• Communicate barriers, challenges and any other issues that affect progress.

Budget and Financial Management

• May be responsible for appropriate use of funds and resources.

• Prepare documentation and projections to support new programs and the budget planning process.

• Monitor monthly performance reports and budget variances and resolve discrepancies as needed.

Safety

• Speak up when team members appear to exhibit unsafe behavior or performance

• Continuously validate and verify information needed for decision making or documentation

• Stop in the face of uncertainty and takes time to resolve the situation

• Demonstrate accurate, clear and timely verbal and written communication

• Actively promote safety for patients, families, visitors and co-workers

• Attend carefully to important details - practicing Stop, Think, Act and Review in order to self-check behavior and performance

Organizational Accountabilities
Program Management/ Coordination

• Assist in the development of project scope statements, timelines, and deliverables; assign work to team members to assure timely completion of project and on budget.

• Implement project plans according to schedule in order to achieve desired results.

• Independently conduct comprehensive data gathering and analysis efforts.

• Coordinates and schedules appointments, meetings and conferences with other CNMC departments and external customers.

Organizational Commitment/Identification

• Partner in the mission and upholds the core principles of the organization

• Committed to diversity and recognizes value of cultural ethnic differences

• Demonstrate personal and professional integrity

• Maintain confidentiality at all times

Customer Service

• Anticipate and responds to customer needs; follows up until needs are met

Teamwork/Communication

• Demonstrate collaborative and respectful behavior

• Partner with all team members to achieve goals

• Receptive to others' ideas and opinions

Performance Improvement/Problem-solving

• Contribute to a positive work environment

• Demonstrate flexibility and willingness to change

• Identify opportunities to improve clinical and administrative processes

• Make appropriate decisions, using sound judgment

Cost Management/Financial Responsibility

• Use resources efficiently

• Search for less costly ways of doing things

Organizational Accountabilities (Staff)
Organizational Commitment/Identification

• Anticipate and responds to customer needs; follows up until needs are met

Teamwork/Communication

• Demonstrate collaborative and respectful behavior

• Partner with all team members to achieve goals

• Receptive to others' ideas and opinions

Performance Improvement/Problem-solving

• Contribute to a positive work environment

• Demonstrate flexibility and willingness to change

• Identify opportunities to improve clinical and administrative processes

• Make appropriate decisions, using sound judgment

Cost Management/Financial Responsibility

• Use resources efficiently

• Search for less costly ways of doing things

Safety

• Speak up when team members appear to exhibit unsafe behavior or performance

• Continuously validate and verify information needed for decision making or documentation

• Stop in the face of uncertainty and takes time to resolve the situation

• Demonstrate accurate, clear and timely verbal and written communication

• Actively promote safety for patients, families, visitors and co-workers

• Attend carefully to important details - practicing Stop, Think, Act and Review in order to self-check behavior and performance