Manager, Hospital Regulatory

Tenet Healthcare has an immediate opening for a Manager, Hospital Regulatory and Accreditation to support the enterprise. This position will require a high percentage of nationwide travel.

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 and USPI, regulatory requirements and accreditation standards, goals, and targets through collaboration with corporate departments and the Sr. Director, Regulatory and Accreditation
• Is a leader for the Clinical Operations Department in the formulation of Tenet and USPI regulatory and accreditation related goals and targets.
• Assists with the development of the Tenet and USPI strategy and tactics for regulatory and accreditation preparation and successful surveys
• Conducts on-site facility surveys
• Provides leadership and expertise in methods of performance improvement.
• Coordinates and collaborates with organizational leaders on activities related to the development, implementation, improvement of and adherence to the organization’s policies and procedures covering the scope of regulatory requirements and accreditation standards
• Supports preparation for surveys (i.e., CMS, TJC, State,)
• Supports the formulation of responses [plans of correction] from surveyors, electronic communication, or third-party payers under the direction of the Sr. Director of Regulatory and Accreditation
• Remains current concerning industry-wide, leading practices
• Demonstrates ethical behavior in decision-making, performance of job responsibilities while maintaining confidentiality regarding patient information, quality, performance, and peer review information.
• Develops policies and procedures for areas of responsibility.
• Develops 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:

• Required: Registered Nurse with advanced degree in relevant field plus five years of regulatory, accreditation, and performance improvement experience or Advanced degree in a health-related field (Masters) with five years of relevant regulatory, accreditation, and performance improvement experience.
• A minimum of 75% national travel annually is a requirement. Selected candidate will be required to pass Motor Vehicle Record check and maintain valid driver’s license.
• Experience leading interdisciplinary initiatives in process improvement and directly with improving reliability of healthcare delivery at the point of care.
• Functional knowledge of TJC, CMS COP’s, and other federal and state requirements regulatory standards.
• Relevant experience in healthcare/clinical setting.
• Strong organizational, written, communication, and presentation skills.

REQUIRED CERTIFICATION:

• Certified Joint Commission Professional (CJCP) or Certified Professional Healthcare Quality (CPHQ) within twelve months of hire date.

SKILLS, KNOWLEDGE, AND ABILITIES:

• Skilled at developing and conducting educational presentations.
• Adept at developing methods, tools, reports, data aggregation and conducting regulatory and operational surveys for USPI facilities, including the review of regulatory requirements and accreditation standards and Conditions of Participation.
• Prepares written reports of clinical and operational survey findings.
• 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
• Polished communicator (written, verbal and presentation skills) with many levels of key stakeholders from the board level to the point of care staff.
• Expert with working, leading, following, coordinating, and managing activities to driving change within Tenet/USPI to achieve strategic initiatives for clinical/operational initiatives related to regulatory and accreditation.

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.
• Electronic Health Record
• eSRM (Risk Management System)
• Balanced Score Card / Clinical Operations Scorecard
• SharePoint
• AMP with Tracers

Travel

• A minimum of 75% national travel annually is a requirement.
  • Selected candidate will be required to pass Motor Vehicle Record check

Compensation

• Pay: $114,192-$165,000 annually. Compensation depends on location, qualifications, and experience.
• Position may be eligible for an Annual Incentive Plan bonus of 10%-25% depending on role level.
• Management level positions may be eligible for sign-on and relocation bonuses.

Benefits

The following benefits are available, subject to employment status:

• Medical, dental, vision, disability, life, AD&D and business travel insurance
• Manager Time Off – 20 days per year
• Discretionary 401k match
• 10 paid holidays per year
• Health savings accounts, healthcare & dependent flexible spending accounts
• Employee Assistance program, Employee discount program
• Voluntary benefits include pet insurance, legal insurance, accident and critical illness insurance, long term care, elder & childcare, auto & home insurance.
• For Colorado employees, paid leave in accordance with Colorado’s Healthy Families and Workplaces Act.

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Employment practices will not be influenced or affected by an applicant’s or employee’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 participates in the E-Verify program. Follow the link below for additional information.
E-Verify: http://www.uscis.gov/e-verify
The employment practices of Tenet Healthcare and its companies comply with all applicable laws and regulations.