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Director Licensure & Accreditation

Location Harbor City, California Job Number 967674 Date posted 09/13/2021
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Manages, facilitates and supports activities relating to licensure, accreditation, and regulatory compliance within the Service Area, including preparation for, compliance with, and follow up for all surveys such as GACH, The Joint Commission, California Department of Public Health, Medicare & Medicaid Services, California Children's Services, NCQA, College of American Pathologists, etc. Collaborates with administrators, managers, chiefs of service and other physician leaders to assist with and coordinate all regulatory functions/efforts. Ensures that all areas of vulnerability with regard to accreditation and licensing are identified. Works with individuals and/or teams to develop corrective action plans.

Essential Responsibilities:
  • Serves as the primary contact for all accreditation, licensure, and regulatory agencies.
  • Provides consultative services to all KFH/P and SCPMG departments and services regarding intent of regulations and means to maintain compliance.
  • Keeps abreast of changes in legislation and requirements related to regulatory, accreditation, and licensure issues. Collaborates and coordinates with departments/individuals on any implementation and evaluation of legislation affecting the service area to maintain compliance.
  • Provides oversight of the Service Area Administrative Policy Manual process to maintain compliance as designated by the board of directors.
  • Assures continuity and consistency in compliance with regulatory issues across the organization by evaluating the impact of specific issues.
  • Collaborates with departments to develop and implement corrective action to minimize negative impact and maximize learning.
  • Identifies key accreditation, regulation and licensing issues and defines areas for improvement.
  • Relays internal/external communication of information related to accreditation, regulation and licensure.
  • Continuously prepares for surveys and inspections for all regulatory and accrediting agencies.
  • Maintains relationship with representatives of regulatory agencies.
  • Provides overall staff support to the Accreditation and Licensing Committee such as to coordinate activities and agenda, to manage meeting minutes and action plans, and to provide research analysis and recommendations for issues.

  • Basic Qualifications:


    • Minimum five (5) years in health care.

    • Minimum three (3) years in management


    • Bachelor's degree in Health Care Administration, Public Health, nursing or other related field or four (4) years of experience in a directly related field required.

    • High School Diploma or General Education Development (GED) required.

    License, Certification, Registration

    • N/A.


    Additional Requirements:

    • Working knowledge of federal and state laws and regulations such as TJC, NCQA, GACH, Title 22, CCS,CMS COPs.

    • Demonstrated experience in adult education and motivational theories, statistical analysis and quality management process.

    • Excellent oral and written communication skills.

    • Must be able to work in a Labor/Management Partnership environment.


    Preferred Qualifications:

    • Clinical experience and clinical operations management preferred.

    • Ability to engage others, build teams and foster an internal culture of continuous survey readiness and compliance preferred.

    • Ability to effectively translate legal provisions and industry standards into practical applications processes and procedures preferred.

    • Skills in Policy/Procedure development, review, analysis, revision and document retention preferred.

    • Demonstrated ability to navigate through statutes, regulations, standards, as well as recommendations and guidelines from nationally recognized organizations such as the Centers for Disease Control and Prevention (CDC), the Association for Professionals in Infection Control and Epidemiology (APIC), the Association for the Advancement of Medical Instrumentation (AAMI), the Association of perioperative Registered Nurses (AORN), the National Fire Protection Association (NFPA), the U.S. Occupational Health and Safety Administration (OSHA) Technical Manuals, to determine applicability, commonalities, enforcement, and to develop a comprehensive, cohesive approach to compliance.

    • Master's degree preferred.

    Primary Location: California,Harbor City,South Bay Medical Center Scheduled Weekly Hours: 40 Shift: Day Workdays: Mon, Tue, Wed, Thu, Fri Working Hours Start: 08:00 AM Working Hours End: 05:00 PM Job Schedule: Full-time Job Type: Standard Employee Status: Regular Employee Group/Union Affiliation: NUE-SCAL-01|NUE|Non Union Employee Job Level: Individual Contributor Department: South Bay Med Center - Hospital Administration - 0801 Travel: Yes, 10 % of the Time Kaiser Permanente is an equal opportunity employer committed to a diverse and inclusive workforce. Applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy), age, sexual orientation, national origin, marital status, parental status, ancestry, disability, gender identity, veteran status, genetic information, other distinguishing characteristics of diversity and inclusion, or any other protected status.

    External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with federal and state laws, as well as applicable local ordinances, including but not limited to the San Francisco and Los Angeles Fair Chance Ordinances.