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Accreditation/Regulatory Internal Assurance Mgr at Nicklaus Children's Health System in Miami, Florida

Posted in Health Care 30+ days ago.

Type: Full-Time





Job Description:

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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