Manager, Accreditation and Licensure

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Organization : CPMC-California Pacific Med Center Van Ness

Position Overview : Responsible and accountable to develop and coordinate components of performance improvement programs and ensure entity is in compliance with accreditation standards, state and federal regulations and other identified standards. The responsibility includes resource management, regulatory compliance and participation in quality improvement activities. To facilitate improvement activities, and to serve as a resource to assist and train others on performance improvement methodologies and evidence-based patient safety and quality initiatives. To coordinate activities related to licensing and accreditation compliance and continuous survey readiness. The position provides guidance, team facilitation, training & support for performance improvement and special projects within the organization. Act as the primary point of contact for entities' survey readiness improvement needs and facilitates communications.

Job Description :

Education : Bachelor's : Management, public health, nursing, business administration, organizational leadership or related field

Typical Experience : 8 years of recent relevant experience

Skills and Knowledge : Operations, leadership, critical thinking, analysis, teaching, facilitation, coaching, mentoring, and project management skills required. Knowledge of population health management practices, policy, programs, initiatives, and functions.

Ability to train staff in various quality improvement and performance improvement methodologies.

Exemplary written and oral communication skills, including presentations and comprehensive analysis reporting on performance improvement issues.

Ability to partner and collaborate with physician leadership and work effectively with providers and physician site leadership. Ability to analyze problems, to reach practical conclusions, and institute effective changes.

Ability to evaluate staff performance, identify behavior and performance problems, and staff development needs, and take appropriate actions as necessary.

Advanced computer skills in Microsoft Office : [Word, Excel, Outlook, and PowerPoint] EPIC, Midas. Ability to implement department policies and procedures and ensure adherence.

Must have organizational skills and the ability to balance numerous priorities at the same time, be detail-oriented, self-directed, and able to work with minimal supervision.

Ability to compile, organize, summarize, prepare in text or graphic form, and proofread extensive spreadsheets and data from a variety of sources. Ability to write executive summaries.

Must be able to deal appropriately with confidential and sensitive information and to demonstrate diplomacy, tact, and a high level of professionalism.

Organizational skills, ability to work on multiple projects under multiple deadlines; must be highly energetic, and able to embrace challenges and change. Must be a team player and work well with a variety of people at all levels of the organization.

Experience leading safety / quality / clinical effectiveness initiatives with a high level of independence.

Experience in successfully facilitating collaborative, cross-functional projects, including the ability to define program, project, or process objectives, identify stakeholders and their interests, plan steps, coordinate and allocate human, technological, and fiscal resources to accomplish goals and objectives in a resourceful and timely manner.

An in-depth knowledge of regulations and guidelines for governing areas of responsibility.

Job Shift : Days

Schedule : Full Time

Days of the Week : Monday - Friday

Weekend Requirements : As Needed

Benefits : Yes

Unions : No

Position Status : Exempt

Weekly Hours : 40

Employee Status : Regular

Sutter Health is an equal opportunity employer EOE / M / F / Disability / Veterans.

Pay Range is $66.99 to $100.49 / hour