Description: Job Summary:
Conducts regulatory audits and surveys by independently keeping current on regulatory requirements in preparation for surveys. Assists in facilitation of on-site visits and evaluations. Performs site visits in accordance with criteria to ensure survey readiness. Ensures completion of surveys, with regular review by manager. Conducts routine audits and mock surveys to aid in preparedness, tracking, trending, and aiding in the facilitation of corrective action plans. Collaborates with others to complete annual reporting. Ensures licensing and accreditation by reviewing requirements for new, expanding, and existing facilities/services in relation to relevant accrediting standards, evaluating relevant risk and impact with regular review. Consults with departments to ensure certification and conducts basic gap analyses for standard and nonstandard cases. Serves as the subject matter expert by maintaining and beginning to facilitate awareness of internal policies and consulting on the interpretation and interaction of current policies, and how they interact with the current climate, and potential changes to regulations and legislation. Develops standard and nonstandard content and delivers education programs to align policies with regulatory requirements. Conducts data management by entering and analyzing practitioner/provider data to develop action plans for timely implementation.

Essential Responsibilities:
Pursues effective relationships with others by proactively providing resources, information, advice, and expertise with coworkers and members. Listens to, seeks, and addresses performance feedback; provides mentoring to team members. Pursues self-development; creates plans and takes action to capitalize on strengths and develop weaknesses; influences others through technical explanations and examples. Adapts to and learns from change, challenges, and feedback; demonstrates flexibility in approaches to work; helps others adapt to new tasks and processes. Supports and responds to the needs of others to support a business outcome.
Completes work assignments autonomously by applying up-to-date expertise in subject area to generate creative solutions; ensures all procedures and policies are followed; leverages an understanding of data and resources to support projects or initiatives. Collaborates cross-functionally to solve business problems; escalates issues or risks as appropriate; communicates progress and information. Supports, identifies, and monitors priorities, deadlines, and expectations. Identifies, speaks up, and implements ways to address improvement opportunities for team.
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 auditing processes; and developing standard and nonstandard content and delivering educational programs to align organizational policies and procedures with regulatory requirements.
Conducts data management by: entering practitioner/provider data into the appropriate database; and entering, analyzing, and suggesting additions to draft action plans/recommendations required data into appropriate databases.
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., NCQA, Joint Commission, AAAHC), with regular review from manager; assisting with on-site visits and evaluations as directed; leveraging standard and nonstandard 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 Supervisor on the status of survey completion as required for auditing surveys, focusing on high vulnerability areas. Minimum Qualifications:
Minimum one (1) year 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.
Additional Requirements:
Knowledge, Skills, and Abilities (KSAs): Credentialing Database Systems; Health Care Quality Standards; Health Care Policy; Health Care Data Analytics; Managing Diverse Relationships; Delegation; Risk Assessment; Evidence-Based Medicine Principles Preferred Qualifications:Certified Professional in Healthcare Quality (CPHQ).Certified Joint Commission Professional (CJCP) or credential(s) from the Healthcare Accreditation Certification Program(s) (HACP).Three (3) years of National Committee of Quality Assurance (NCQA) or related survey experience.