Accreditation, Regulatory, and Licensing Specialist IV, Clinical

In addition to the responsibilities listed above, this role is also responsible for: independently scheduling and performing the site reviews, medical record reviews, and Physical Accessibility Review (PAR) surveys; independently conducting site visits for ambulatory care and affiliated sites, as needed; independently planning and enacting plans to ensure survey performance is in accordance with all regulatory requirements via rounds with staff, leaders, and providers; building educational moderately complex principles for the relevant topic (e.g., stroke certifications) to aid staff understanding of organizational priorities; evaluating alignment of patient care towards standards and statues within the program as well as compliance with regulatory, accreditation programs, and national guidelines, with limited direction; serving as a consultative resource for moderately complex regulatory and accreditation programs recommendations, relevant program practice guidelines, order sets; conducting the planning and execution of short term Ambulatory Surgery Centers/Units (ASCs or ASUs) quality and patient safety priorities, in alignment with regional and organization-wide goals; beginning to guide others to develop and implement regional strategies that include a region-wide plan for routine surveillance of quality and patient safety systems and policy administration in the regions ASCs/ASUs; participating in regional cross-functional teams, as appropriate, to drive clinical improvements and efficient use of resources; guiding others in supporting Graduate Medical Education (GME) for non-physician roles (Hospital Markets Only); independently communicating moderately complex regulatory, policy, patient safety and quality program status and issues to program leads, business owners, and leadership; exercising judgement and discretion to aid in consultations for regulatory and accreditation programs recommendations, relevant program practice guidelines; and coordinating and maintaining clinical and service quality improvement activity summaries for regulatory oversight bodies.

• Promotes learning in others by proactively providing and/or developing information, resources, advice, and expertise with coworkers and members; builds relationships with cross-functional/external stakeholders and customers. Listens to, seeks, and addresses performance feedback; proactively provides actionable feedback to others and to managers. Pursues self-development; creates and executes plans to capitalize on strengths and develop weaknesses; leads by influencing others through technical explanations and examples and provides options and recommendations. Adopts new responsibilities; adapts to and learns from change, challenges, and feedback; demonstrates flexibility in approaches to work; champions change and helps others adapt to new tasks and processes. Facilitates team collaboration to support a business outcome.


• Completes work assignments autonomously and supports business-specific projects by applying expertise in subject area and business knowledge to generate creative solutions; encourages team members to adapt to and follow all procedures and policies. Collaborates cross-functionally and/or externally to achieve effective business decisions; provides recommendations and solves complex problems; escalates high-priority issues or risks, as appropriate; monitors progress and results. Supports the development of work plans to meet business priorities and deadlines; identifies resources to accomplish priorities and deadlines. Identifies, speaks up, and capitalizes on improvement opportunities across teams; uses influence to guide others and engages stakeholders to achieve appropriate solutions.


• Serves as the subject matter expert for regulations within assigned departments by: maintaining awareness of current internal policies and external regulations, and legislation; providing consultation on the interpretation, interaction, and implementation of current policies, regulations, and legislation, with guidance from senior colleagues; attending committees and actively contributing consultative guidance on the enforcement of regulations and auditing processes; developing moderately complex content and delivering educational programs to align organizational policies and procedures with regulatory requirements; and identifying and escalating issues and seeking input from leadership to resolve.


• Conducts data management and reporting support by: entering practitioner/provider data into the appropriate database; and entering, analyzing, and independently drafting action plans/recommendations required data into appropriate databases and providing consultative expertise during implementation of action plans.


• Ensures licensing and accreditation by: independently reviewing requirements for new, existing, and expanding facilities/services to aid in achievement of compliance with state, federal, and accrediting standards; consulting with other departments to ensure certification for moderately complex cases; and independently conducting a nuanced gap analysis and mentoring others to identify services renewals and planning to ensure services are compliant.


• Conducts regulatory audits and surveys by: independently reporting moderately complex and keeping current on regulatory requirements in preparation for surveys (e.g., NCQA, Joint Commission, AAAHC); coordinating with departments and external representatives to organize and support on-site visits and evaluations; independently conducting, reviewing, evaluating upon site visit criteria, and performing site visits as appropriate to ensure survey readiness delivering requested audit documentation, information, and reports; coordinating with stakeholders within designated department to ensure the completion of required auditing surveys, focusing on high vulnerability areas; aiding in the facilitation of educational forums and conducting standard routine audits and mock surveys within departments to ensure auditing and survey preparedness. tracking, trending, and facilitating the development of corrective action plans (CAP) as necessary in collaboration with applicable departments to assure site visit compliance; and collaborating with other departments (e.g., Revenue Cycle), gathering documents and data to support the timely completion of the annual state/federal/regulatory body reporting as required.