The best thing about this role Are you looking to make a difference by improving the health of our patients? Here you will find an innovative culture that is patient-focused and dedicated to making a difference. We are committed to helping the population we serve, and our communities, achieve optimum health and enjoy the best quality of life possible. What you'll do The Clinical Accreditation and Regulatory Readiness Manager reports to the Director Accreditation and Regulatory Readiness. The Clinical Accreditation and Regulatory Readiness Manager provides and supports regulatory, accreditation and certification activities to achieve and sustain ongoing compliance. Takes action to assure timely and complete preparation, support and follow up to surveys, reviews and investigations. Represents the Bassett Healthcare Network (BHN) in interfaces with regulatory and accreditation agencies. Remains current with state and federal regulations and communicates that information within the BHN. Works closely with leaders to develop and implement plans to meet new or revised regulations or standards. In cooperation with the accreditation team collaborates with BHN department leaders to promote and maintain regulatory compliance. Collaborates in facilitating regulatory survey readiness program planning to support BHN’s mission, vision, values and business objectives with duties including but not limited to: Facilitate survey readiness activities to comply with regulatory and accreditation requirements, including CMS, TJC/DNV-GL, and State audits Collaborates with Director to assess survey readiness of entities/departments/services and provides consultation where indicated Interpreting applicable regulatory standards and guides improvement activities for compliance Collaborating with stakeholders to identify organizational gaps for survey readiness, implementing processes to meet standards, and monitoring progress for completion Developing an organized system to access, collect and document each department’s (Chapter Champions) level of compliance with applicable standards Actively preparing and participating in on-site surveys, including coordination of agendas, assigning tasks, tracking activities and communication plans for internal and external stakeholders Facilitating and conducting mock surveys or audits and developing plans for improvement Is accountable to collaborate with others to ensure that necessary plans of action are completed and submitted to regulatory, accreditation and/ or standards organizations by indicated due dates Participating in departmental and organizational meetings for survey readiness Establishes mechanisms for proactive identification and correction of regulatory issues with duties including but not limited to: Collaborating with stakeholders to support a culture of continuous survey readiness Acting as a resource for all staff in the organization on regulatory, accreditation, and survey readiness Developing and revising policies and procedures to comply with guidelines and regulatory standards Supports, facilitates, and participates in departmental, affiliate, and system committees and project teams as assigned to achieve regulatory and accreditation compliance Continually monitoring and tracking opportunities for improvement in an organized, systematic and on-going basis Reviewing corrective action plans for appropriateness, effectiveness and completion Interpreting and assisting in planning responses to new, revised, or upcoming regulations or standards Providing feedback regarding external regulatory bodies to develop standards that promote high quality care, evidence-based practices and alignment with applicable regulations Assisting and preparing departmental reports, studies and audits as needed Ensuring accuracy of data analytics in the department both for internal use and public reporting as applicable Provides guidance and utilizes quality improvement tools and techniques to address deficiencies Remaining current and knowledgeable of all present and proposed quality mandates from regulatory bodies Conducts training and coaching to facilitate understanding of accreditation standards and requirements Developing presentations and effectively communicating survey readiness information to all levels of the organization Developing internal and external communication related to accreditation and regulation information Providing a learning environment to meet accreditation and regulatory requirements Developing templates, tools and processes to facilitate an efficient and effective means for regulatory compliance Provides mentoring and coaching of care providers regarding aspects of onsite survey inspections Collaborating with internal and external stakeholders to proactively identify and define areas for improvement for survey readiness activities Performs other duties as requested and observed by director What we need from you Education: 4 Year / Bachelor's Degree, Bachelor’s Degree in nursing, public health, healthcare administration, business administration or health related field, required Master's Degree, preferred Experience: 5 years minimum experience with accreditation and regulatory survey processes OR experience in Quality Improvement or management experience, required Prior experience as a project lead working with an accrediting agency highly desirable, preferred Previous supervisory experience, preferred Licensure/Certifications: NYS RN License, required Must obtain an additional certification relevant to Regulatory Readiness with in 2 years of hire. Examples may include; -DNV CHOP Series -Vizient Certification prep -Healthcare Accreditation Certification Program (HACP) -National Fire Protection Agency training -Certified Healthcare Quality Professional Skills: Project Management/Planning Accountability Analysis & Evaluation Attention to Detail Computer Skills Creative Thinking Critical Thinking Facilitate Logical Thinking Time Management Strategic Thinking Physical Requirements: Light Work - Exerting up to 20 lbs of force frequently, and/or a negligible amount of force constantly to move objects. If the use of arm and/or leg control requires exertion of forces greater than that of sedentary work and if the worker sits most of the time, the job is considered light work Occasional crouching, grasping, kneeling, lifting, pulling, pushing, reaching, repetitive motion, standing, stooping, walking Constant typing/clerical/dexterity, hearing, seeing/monitor/computer use, talking Travel: Extensive Travel - You should expect to travel every week Total Rewards Bassett Healthcare Network’s commitment to our employees includes benefit programs carefully designed with the needs and values of all our employees in mind. Many of the benefits we offer are paid fully or in large part by Bassett. Our generous benefits offerings include: Paid time off, including company holidays, vacation, and sick time Medical, dental and vision insurance Life insurance and disability protection Retirement benefits including an employer match And more! Specific benefit offerings may vary by location and/or position. Pay Transparency Salary is based on a variety of factors, including, but not limited to, qualifications, experience, education, licenses, specialty, training, and fair market evaluation based on industry standards. The above compensation range represents a good faith belief of the compensation range by Bassett Healthcare Network, and its entities and affiliates, at the time of this posting or advertisement. Pay Range Minimum: USD $87,817.60/Yr. Pay Range Maximum: USD $131,726.40/Yr. We love the difference people bring We provide equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, creed, sex (including pregnancy, childbirth, or related condition), age, national origin or ancestry, citizenship, disability, marital status, sexual orientation, gender identity or expression (including transgender status), genetic predisposition or carrier status, military or veteran status, familial status, status as a victim of domestic violence, or any other status protected by law.