Southcoast Health System, Inc.

Director-Regulatory Readiness-Accreditation

Location US-MA-New Bedford
ID 2024-36444
Schedule
Regular Full-Time
Remote
No
Department
SC-Clin Quality

Overview

Community Focused. Care Driven. 

 

Join Southcoast Health, where your future is as promising as the care we provide. Our commitment to each other, our patients, and our community is more than a mission - it’s our way of life, and you’ll be at the heart of it. 

 

Southcoast Health is a not-for-profit, charitable, health system with multiple hospitals, clinics and facilities throughout Southeastern Massachusetts and Rhode Island.  

 

Nestled in local communities, Southcoast Health provides inclusive, ethical workplaces where our highly skilled caregivers offer world-class, comprehensive healthcare close to home. 

 

Find out for yourself why Southcoast Health has been voted ‘Best Place to Work’ for 6 years in a row! 

 

We are searching for a talented Director-Regulatory Readiness-Accreditation 

 

  

A career at Southcoast Health offers you: 

  • A culture of well-being that embraces, respects, and celebrates the rich diversity of one another and the communities we serve 
  • Competitive pay and comprehensive benefits package 
  • Generous Earned Time Off Package** 
  • Employee Wellbeing Program 
  • 403B Retirement Plan with company match 
  • Tuition assistance / Federal Loan Forgiveness programs 
  • Professional growth opportunities and customized leadership training 

**Available to regular status employees who are scheduled to work a minimum of 24 hours. 

Southcoast Health is an Equal Opportunity Employer. 

 

Compensation: Pay rate will be determined based on level of experience. 

 

Responsibilities

Reports to the Executive Director of Quality Outcomes and includes a wide variety of duties leading and managing all aspects of continuous regulatory readiness and the accreditation process (i.e. JC, CMS, and other agencies) for the system. This includes SHG hospitals and hospital-licensed offsite facilities, SPG including Urgent Care Centers, Specialty, Retail pharmacy, and Southcoast VNA services. Works collaboratively with Risk Management in DPH and OSHA visitation or survey as needed. Responsible for providing consultation, interpretation, and implementation of accreditation or certification activities for SHG hospital and hospital- licensed facilities seeking accreditation or reaccreditation on Disease Specific Certifications. Provide strategic and tactical guidance to SHS leadership, SHG Regulatory Readiness Committee and other SHS parties on accreditation readiness requirements through consultation, facilitation, project management, and collaborative improvement activities. Facilitates the clinical and administrative policy committees for correlation and timely review of needed policies based on standard requirements and organizational need. Maintains updated applications for all system accreditations, completes submissions and responds timely to accreditation agency's inquires.

Qualifications

  • A Masters degree or equivalent experience in a related professional field is required, and nursing degree preferred.
  • Experience with evaluation, managing and supporting organizational accreditation programs (Joint Commission or other accreditation agencies, and CMS) is required.
  • Experience and working knowledge of quality improvement principles required.
  • Lean Six Sigma certification or equivalent process improvement certification or experience preferred upon hire or Lean certification within the first year of the position.
  • Clinical, financial, and manager experience with business or office automation preferred.
  • Project management experience, leading, and organizing teams preferred.
  • Working knowledge of all Microsoft Office software applications required.
  • Minimum of seven (7) years of related work experience is also required including experience interpreting and applying regulatory standards in a healthcare environment.
  • Must be fully vaccinated against seasonal Influenza and the COVID 19 virus or to be exempt from the requirement for medical or personal reasons by signing a statement certifying you are choosing to be exempt from vaccination once hired

Pay Range

USD $130,000.00 - USD $170,000.00 /Yr.

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