Accreditation and Regulatory Specialist, Clinical

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Department:
Accreditation & Regulatory

Under the direction of the Director of Accreditation and Regulatory and organizational leaders, the Accreditation and Regulatory Specialist, Clinical will serve as an internal resource on Joint Commission, CMS, CDPH, and Title 22 standards and is responsible for coordinating all licensure and accreditation activities during surveys and licensing inspections.

The Specialist works under the Director of Accreditation and Regulatory to assist in creating, implementing, and maintaining the strategy and tactics to ensure that SVH is continually prepared for Joint Commission accreditation, CDPH licensure, federal and state regulatory surveys,
and compliance with all pertinent regulatory and accreditation requirements.

The Specialist must be able to work autonomously under general direction, establishing day-to-day working priorities and long-range planning to achieve timely and quality results.

This position will also demand expert writing skills, public speaking, and one-on-one consulting skills.

1.

CDPH and CMS Licensing Activities: Collaborates with Director of Accreditation and Regulatory by coordinating the California Department of Public Health (CDPH) and Centers for Medicare and Medicaid Services (CMS) on surveys and evaluations, both announced and unannounced, conducted by
those agencies, including, but not limited to, the following: Serves as coordinator for all matters concerning the state licensure of SVH, works with SVH departments regarding pre-licensing inspections in the hospital and clinics, prepares and submits licensing applications and supplementary profile information when changes are brought about by the creation of new or remodeled patient care locations, change of beds, services, or administrators, new equipment, construction, and other changes that necessitate changes in the hospital license, inspection by CDPH, and special permits or variances.

Prepares the application and supporting documents for the annual relicensing of SVH by CDPH and
arranges for payment of the relicensing fee.

Ensures that services listed on the hospital license accurately represent the services provided.

Prepares, drafts, submits, and renews Program Flexes for approval by CDPH, coordinating as needed with SVH Department managers, Facility Planning, and Health Care Access and Information (HCAI).

Formulates and recommends responses to CDPH statements of deficiency and other agency administrative reviews.

Investigate situations, processes, and policies, collaborate with SVH leaders and staff to identify effective corrections in response to survey findings, assist departments with implementation of plans of corrections, assimilate information and data, write plans of corrections, reports, and memos, and oversee compliance monitoring activities.

Works closely with F...