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Director Accreditation, Regulation, and Licensing

Location Oakland, California Job Number 1001347 Date posted 10/06/2021
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Directs the Medical Center's operations and activities to comply with all accreditation, regulation, and licensing requirements for all health care sites and services across the continuum including, but not limited to: home health, ambulatory services, provider networks, hospital services and health plan. Translates various accrediting, regulatory and licensing agency requirements into action plans to achieve positive survey/audit reviews and renewed licenses. Implements systems to effectively monitor compliance to standards and to implement new processes to meet new requirements.

Essential Functions:

- Directs the Medical Center's operations and activities to comply with all licensing and accreditation standards and requirements, ensuring consistency with organizational goals and priorities. Works closely with designated Chiefs of Service and Department Managers to ensure that principles of confidentiality and responsibility are adhered to. Determines strategy for changing existing processes to meet regulatory
requirements and translating external demands into program goals.
- Provides education and technical support to the Medical Center in developing, implementing and maintaining regulatory compliance. Partners with Risk Management to reduce medical/legal liability through development of a program which links risk management activities with those of regulatory compliance. Serves as a critical link in the identification and resolution of issues, which affect organizational image.
- Develops and maintains relationships and effective communication with all levels of medical center physicians and staff in order to facilitate problem identification and resolution. Manages staff and makes recommendations regarding the need for staff, space and other resources. Manages and resolves human resources and labor relations issues specific to management responsibilities. Develops systems, templates, tools and processes to identify and monitor indicators which best measure improvement in care delivery.
- Analyzes, interprets and makes recommendations to meet federal, state and local requirements. Identifies key accreditation, regulation and licensing issues and defines areas for improvement. Establishes mechanisms for proactive identification of regulatory issues and tracking of corrective action to minimize negative impact and maximize learning. Relays internal/external communication of information related to accreditation, regulation and licensing. Partners with the Quality Director to prepare for surveys and inspections, including educational forums, coordinating mock surveys and assessments assists in developing response plans.
- Coordinates formal surveys for all regulatory and accrediting agencies. Interprets and assists in planning responses to new or changing regulations or standards. Collaborates with external regulators to develop standards that promote high quality patient care and services. Serves as liaison to region, community groups, professional organizations, and licensing/regulatory agencies. Develops, implements, and meets the established financial goals. Monitors applicable budget; and identifies and supports solutions to reduce cost structure.
- Kaiser Permanente conducts compensation reviews of positions on a routine basis. At any time, Kaiser Permanente reserves the right to reevaluate and change job descriptions, or to change such positions from salaried to hourly pay status. Such changes are generally implemented only after notice is given to affected employees.

Basic Qualifications:


• Minimum five (5) years of experience in Quality Improvement in a health care setting.


• Bachelor's degree in health care administration, nursing, or public administration or related field required.

License, Certification, Registration

• N/A


Additional Requirements:

• Demonstrated knowledge of governmental & other regulatory standards, requirements, & guidelines related to quality improvement, such as The Joint Commission, NCQA, Knox-Keene Act, Federal HMO Act, CMS Conditions of Participation, Title 22, Cal-OSHA, HIPAA & Medical & Medicare regulations & standards.

• Strong working knowledge of ongoing monitoring techniques (including criteria development & statistical analysis); medical care delivery in hospital & outpatient settings; total quality management principles, tools, & techniques.

• Effective communication, negotiation, & leadership skills.

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


Preferred Qualifications:

• Previous management experience in nursing or other allied health professional experience preferred.

• Experience designing, developing, and implementing clinical improvement programs.

• Previous management experience.

• Clinical licensure or master's degree in health care administration, nursing, or public administration or related field preferred.

• Total Quality Management certification or Certified Professional of Healthcare Quality (CPHQ) preferred.


• CDPH Experience

Primary Location: California,Oakland,1950 Franklin 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-NCAL-09|NUE|Non Union Employee Job Level: Director/Senior Director Department: Oakland Reg - 1950 Franklin - Rgnl Accred Regulation & Lic - 0201 Travel: Yes, 20 % 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.