SUMMARY

Reporting to the Chief Medical Officer, this position has oversight responsibility and provides strategic direction for Saint Agnes Regulatory, Accreditation and Licensing.  The incumbent is accountable to work collaboratively with hospital leaders and medical staff to ensure compliance with regulatory, accreditation and licensing entities and standards, and coordination of key processes and improvement efforts.  This includes ensuring Saint Agnes systems, structure, processes, practices, and policies are meeting standards related to maintaining full licensure and accreditation.  

The director is responsible for promoting a de-centralized model for continuous survey readiness, collaborating with other members of the Accreditation team in development of a functional team infrastructure that supports individual accountability for compliance with the Joint Commission (TJC) and Center for Medicare & Medicaid Services (CMS) standards.  The incumbent also ensures compliance with standards and coordination of key processes and improvement efforts.

This position also collaborates with the Director of Quality and Infection Prevention to support the development of strategic quality and safety initiatives that are aligned with organizational objectives. In addition, in collaboration with the Risk Management team, serves as liaison to the California Department of Public Health (CDPH) and other pertinent regulatory agencies. This position maintains a liaison reporting relationship to Trinity Risk Management Services.

REQUIREMENTS

1. Bachelor's degree in Health Administration, Business, or a related field is required. Master's degree is preferred.
2. Five (5) years’ experience in a leadership role or managerial function is required.
3. Demonstrated experience in performance improvement and continuous quality improvement methodologies is required.

4. In depth understanding of regulatory requirements and healthcare operations is required.
5. Certified Professional in Healthcare Quality (CPHQ) issued by National Association for Healthcare Quality (NAHQ) is preferred.
6. Knowledge of Joint Commission Accreditation standards, CMS' Conditions of Participation and Title XXII regulations is required.
7. Specific skills including well developed leadership ability, strong interpersonal and written communication skills, project management, and team-building expertise are required.

Pay Range ($56.70 - $85.06)

Our Commitment to Diversity and Inclusion
 

Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is 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, status as a protected veteran, or any other status protected by law.