Directly supports the Director of Accreditation and Patient Safety and NAH leadership in the effective implementation and maintenance of all NAH accreditation activities. Develops, operationalizes, and administers the accreditation program on a day-to-day basis, gathering information, maintaining documentation, reporting data, and providing educational programs, all with the objective of securing consistent accreditation and related designations, improving clinical quality processes, controlling and minimizing Northern Arizona Healthcare's accreditation and 11censure risks, and to protect employees' and patients' safety. Works closely with the Quality Department, Compliance personnel, and clinical leaders and teams across the organization. Identifies and evaluates emerging accreditation requirements and changes, to implement leading accreditation practices. Provides direct supervision and oversight of the Accreditation Regulatory Specialists.

Quality Management System
*Leads accreditation-related quality management functions and review processes across the system.

* Directs all aspects of the Joint Commission accreditation.

* Supports CMS or AzDHS related surveys and plans of correction.

Internal Audit
* Develops and oversees accreditation-related internal audit and document control programs.

* Communicates with Department management to ensure knowledge of ADHS, CMS, Joint Commission standards and associated continuous readiness, compliance, and continuous quality improvement

Education
* Develops and oversees accreditation-related internal audit and document control programs.

* Communicates with Department management to ensure knowledge of ADHS, CMS, Joint Commission standards and associated continuous readiness, compliance, and continuous quality improvement.

Accreditation Operations
* Oversees and directs Joint Commission accreditation and other regulatory certification surveys.

* Validates effective plans of corrections have been developed and implemented in response to identified nonconformities, deficiencies, or opportunities for improvement.

* Assures appropriate documentation management of plans of correction are maintained.

* Oversee and performs data collection, analysis, and trending to continuously improve processes and outcomes.

* Supports and provides guidance and direction related to regulatory requirements for the optimization of the Environment of Care (EOG} program

Compliance/Safety
* Responsible for reporting any safety related incident in a timely fashion through the Midas/RDE tool; attends all safety related training programs; performs work in a safe manner; monitors work environment for possible safety issues and ensures others are also performing work in a safe manner.

* Maintains confidentiality of all department, patient, and billing matters.

* Completes all company mandatory modules and required job specific training in the specified time frame.

* Stays current and complies with state and federal regulations/statutes and company policies that impact the employees area of responsibility.

Education
Bachelor's Degree in related field- Required
Master's Degree in related field- Required

Experience
Five (5) years in a Healthcare setting such as acute care or multi-specialty clinic - Required
Five (5) years’ experience in a management level administrative, financial, or clinical position in a hospital or health system -
Required
Demonstrated experience in managing people or processes, problem solving and identifying and resolving
operational issues Experience in identifying learning needs as well as providing education and training designed to support a
learning organization Supervisory or management skills as demonstrated through previous experience in a supervisory role.
Experience with Government programs - Strongly Preferred
Prior privacy law, health information management, risk and/or compliance management experience - Strongly Preferred
Prior clinical, patient financial services and/or risk management experience - Preferred

Certification & Licensures