ELIGIBLE FOR CMH EMPLOYEE REFERRAL BONUS: NON-PRIORITY RECRUITMENT The Accreditation, Regulatory, and Licensing Specialist ensures licensing and accreditation by keeping up to date on the requirements for new, expanding, and existing facilities/services in relation to relevant accrediting standards. Consults with departments to ensure certification and conducts basic gap analyses for standard and nonstandard cases. This position serves as the subject matter expert by maintaining internal policies and overseeing organizational compliance of policies. Develops standard and nonstandard content and delivers education programs to align policies with regulatory requirements. Job Requirements Knowledge of/Skill/Ability to: Serves as the subject matter expert for regulations within assigned areas by: maintaining and beginning to facilitate awareness of current internal policies and relevant external regulations, with occasional review; attending committees and actively contributing consultative guidance on the enforcement of regulations and survey processes; and developing standard and nonstandard content and delivering educational programs to align organizational policies and procedures with regulatory requirements. Responsible for compliance with policies within the organization. Ensuring that policies are appropriately approved by the committee in a timely manner. Working with department managers to manage policies, providing guidance on policies that can be archived or combined. Administering policy management system. Training new leaders on policy workflows and system. Ensures licensing and accreditation by: reviewing ongoing licensing and accreditations for new, existing, and expanding facilities/services to aid in achievement of compliance with state, federal, and accrediting standards, with regular review; consulting with other departments to ensure certification for standard and nonstandard cases; and independently conducting a basic gap analysis and mentoring others to identify services renewals and planning to ensure services are compliant. Conducts regulatory audits and surveys by: independently planning for completion of assigned report and keeping current on regulatory requirements in preparation for surveys (e.g., CMS, ACHC, and other regulatory surveys), with regular review from manager(s); assisting with on-site visits and evaluations as directed; leveraging strategies and guidelines to review, evaluate site visit criteria, and perform site visits as appropriate to ensure survey readiness, independently; and preparing requested audit documentation, information, and reports, with regular review; communicating to the manager on the status of survey completion as required for auditing surveys, focusing on high vulnerability areas. License/Certification Preferred: Certified Professional in Healthcare Quality (CPHQ). Preferred: Credential(s) from the Healthcare Accreditation Certification Program(s) (HACP). Preferred: Three (3) years of National Committee of Quality Assurance (NCQA) or related survey experience. Education and/or Experience Minimum two (2) years of experience with databases and spreadsheets. Bachelors degree in Business Administration, Health Care Administration, Nursing, Public Health, or related field AND minimum three (3) years of experience in health care operations, quality, risk management, hospital environment, or a directly related field OR minimum six (6) years of experience in health care operations, quality, risk management, hospital environment, or a directly related field. Physical Demands and Work Environment Conditions / ADA Compliance Sedentary position. Light work. Subject to many interruptions. Must be pleasant in nature and be able to work extremely well under pressure. Must be able to meet deadlines. Must also be able to work very independently with little direction from supervisor. Some evening work required.