Accreditation/Regulatory Internal Assurance Mgr

Job Summary

The Accreditation Regulatory Internal Assurance Manager supports all Nicklaus Children's Health System's (NCHS) entities in accreditation and regulatory readiness & services.

Responsible for developing, implementing, maintaining, and enhancing mechanisms to track, trend, and report Accreditation & Regulatory measures and compliance reports to the NCHS entities.

Assists and/or leads in the preparation, coordination, and execution of efforts related to Det Norske Veritas (DNV) or equivalent National Accreditation entity and other regulatory & governmental agency surveys.

Serves as an expert & supports the department in maintaining its constant state of readiness for all NCHS surveys and continuous process improvement needs to meet regulatory compliance. 

Job Specific Duties


* Supports all Nicklaus Children's Health System's (NCHS) entities in accreditation and regulatory readiness & services. 


* Responsible for developing, implementing, maintaining, and enhancing mechanisms to track, trend, and report Accreditation & Regulatory internal assurance measures and compliance reports to the NCHS entities. 


* Assists and/or leads in the preparation, coordination, and execution of efforts related to Det Norske Veritas (DNV) or equivalent National Accreditation entity and other regulatory & governmental agency surveys. 


* Serves as an expert & supports the department in maintaining its constant state of readiness for all NCHS surveys and continuous process improvement needs to meet regulatory compliance. 


* Analyzes departmental requirements to ensure quality services for internal and external customers aligns with organization's visions and values. 


* Maintains a catalogue of all regulatory & accreditation activities.


* Maintains knowledge of standards, updates to standards, compliance of regulatory requirements through comprehensive document review, analysis, reporting, and summarizing of data. 


* Directly supervises and coordinates activities of extraction workers. 

Minimum Job Requirements


* Bachelor's Degree in Business Healthcare, or related field required 


* 1-3 years’ experience supporting accreditation efforts that include working with state and other regulatory agency representatives, and served as a lead, coordinator, command center representative, escorted agency representatives and/or functioned as a scribe during agency surveys


* 4-7 years’ experience working in healthcare regulatory setting involving accreditation & regulatory preparation and CMS Conditions of Participation standards

Knowledge, Skills, and Abilities


* Master's degree in healthcare related field preferred.


* Quality review, analysis, and reporting as well as quality background preferred.


* Experience with at least three (3) DNV or CMS deemed authority surveys.


* Previous experience in regulatory compliance and or quality improvement is strongly preferred.


* Exceptional attention to detail & presentation skills.


* Excellent verbal, written, and interpersonal communication skills and time management.


* Ability to analyze data and regulatory requirements.


* Ability to interact and consult effectively with leaders, staff, and physicians as well as regulatory bodies.


* High degree of professional judgement, flexibility, and professionalism.


* Experience with informal and formal development of educational programs, policies & procedures, plans and project management skills preferred.


* Advanced knowledge of computer spreadsheets and database management.


* Expert in the fundamental principles of business management, quality management, and performance improvement preferred.


* Demonstration in the understanding and applicability of organizational behavior.


* Independent and creative problem solving to handle complex time sensitive projects.


* Ability to drive to all Nicklaus Children's Health System entities.

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