Healthcare Accreditation & Regulatory Affairs Program Manager Apply
Overview
Fred Hutchinson Cancer Center is an independent, nonprofit organization providing adult cancer treatment and groundbreaking research focused on cancer and infectious diseases. Based in Seattle, Fred Hutch is the only National Cancer Institute-designated cancer center in Washington.
With a track record of global leadership in bone marrow transplantation, HIV/AIDS prevention, immunotherapy and COVID-19 vaccines, Fred Hutch has earned a reputation as one of the worlds leading cancer, infectious disease and biomedical research centers. Fred Hutch operates eight clinical care sites that provide medical oncology, infusion, radiation, proton therapy and related services, and network affiliations with hospitals in five states. Together, our fully integrated research and clinical care teams seek to discover new cures to the worlds deadliest diseases and make life beyond cancer a reality.
At Fred Hutch we value collaboration, compassion, determination, excellence, innovation, integrity and respect. These values are grounded in and expressed through the principles of diversity, equity and inclusion. Our mission is directly tied to the humanity, dignity and inherent value of each employee, patient, community member and supporter. Our commitment to learning across our differences and similarities make us stronger. We seek employees who bring different and innovative ways of seeing the world and solving problems. Fred Hutch is in pursuit of becoming an anti-racist organization. We are committed to ensuring that all candidates hired share our commitment to diversity, anti-racism and inclusion.
The Healthcare Accreditation & Regulatory Affairs Program Manager develops and implements organizational initiatives to support accreditation and regulatory continuous readiness. The scope of the Accreditation and Regulatory Program encompasses 1) standard interpretation, 2) standard compliance, 3) education and communication, and 4) survey operations. Promotes a continuous readiness program that emphasizes quality and patient safety at the forefront of regulatory compliance. Collaborates with external accreditation and regulatory specialists, the organizations content experts, executive sponsors, and medical staff leaders to develop an effective continuous readiness infrastructure that ensures the Program and organizational goals are sustained. Explores opportunities for expanding and standardizing continual readiness initiatives throughout the Organization. Collaborates with colleagues on a state and national level to enhance Fred Hutchs continuous readiness with regulatory and accreditation changes.
Responsibilities
- Serves as a content expert for applicable Washington State Department of Health (DOH), The Joint Commission (TJC), and Centers for Medicare & Medicaid Services (CMS) regulatory and licensing standards.
- Serves as a resource to content experts and executive sponsors in regulatory standards and CMS Conditions of Participation (CoP) interpretation, insight on upcoming regulatory changes, and new regulatory requirements, along with exploring options for operationalizing requirements.
- Proactively leads the ongoing evaluation, planning, and support of the continuous readiness infrastructure and processes to ensure accreditation for regulatory accreditation and hospital licensing.
- Identifies regulatory vulnerabilities and determines when the significance of vulnerabilities warrants bringing them to the attention of the Manager and other organizational leaders.
- Collaborates with Legal Services, Risk Management, Safety, and other departments to ensure regulatory deficiencies are addressed.
- Collaborates with Clinical Operations to develop Clinical Continuous Readiness Cooperative (CCRC) meeting agendas and participates in presenting accreditation and regulatory updates, continuous readiness round results, post-survey regulatory findings, and other regulatory activities that may impact the organization.
- Oversees project prioritization and timeline management of the Accreditation and Regulatory Program.
- Provides guidance on accrediting and certification standards interpretation and other regulatory requirements as they apply to organizational practice.
- Partners with regulatory content experts to identify risk areas and support development, implementation and monitoring of regulatory improvement processes.
- Leads resolution initiatives for complex accreditation and regulatory compliance initiatives.
- Develops and maintains continuous readiness accreditation tools, education and reference materials.
- Ensures regulatory resources are up to date and available to all Fred Hutch clinical leadership and employees on the ARA SharePoint resource page.
- Develops and implements initiatives to evaluate and monitor compliance with regulatory standards through ongoing organizational assessment (i.e. Focused Standards Assessment, tracers, mock surveys, and measurement data).
- Provides applicable regulatory publications, newsletters, alerts, and educational opportunities ensuring pertinent information is communicated to appropriate individuals.
- Collaborates on the development of continuous readiness tracer tools, online ARA resource page, communication plans, and program improvement.
- Collaborates with external partners of Fred Hutch for regulatory initiatives and compliance.
- Serves as a liaison between accreditation/regulatory bodies and Fred Hutch.
- Develops, maintains, and implements organizational Unannounced Survey Plan.
- Manages onsite accreditation and regulatory surveys, including triaging presentations of surveyors and directing command center activities.
- Manages communications, agendas, and logistics for onsite survey activities.Services as liaison between onsite surveyors and Fred Hutch. Manage all ongoing application requirements and corrective action plans.
- Assures applications, Plans of Correction, and other required information under the scope of this position are submitted timely.
- Provides expertise in the development of action plans from the deemed status accrediting organization as well as other regulatory surveys and Intracycle Monitoring.
- Collaborates with content experts and executive sponsors to ensure corrective action plans are implemented, measures are in place, and monitored to sustain accreditation.
- Ensures deemed status accrediting organization applications for accreditation are updated and submitted as required, and as accurately as possible.
- Other duties as assigned.
Qualifications
Required for this Job:
- Bachelor's degree in relevant discipline or relevant health care experience
- Minimum 5 years of experience in a health care environment.
- Current knowledge of hospital regulatory and accreditation standards.
- Strong knowledge of clinical processes and operations in the healthcare system.
- Strong analytical skills to perform data analysis, review statistical reports and identify data needs.
- Ability to excel in a team environment while operating with individual autonomy.
- High-level proficiency in Word, Excel, and PowerPoint.
- Excellent communication (written and verbal) and presentation skills, expert listening, and interpersonal skills.
- Strong interpersonal skills: ability to work effectively with personnel at all levels within the organization.
- Discerning assessment and appropriate decision-making skills, including skills in priority setting and multitasking.
- Critical Thinking ability to synthesize a large amount of information and anticipate needs, draw accurate conclusions.
- Problem Solving ability to grasp details of the situation quickly and convert thinking from listening & learning to facilitating solutions.
Preferred for this job:
- Master's Degree in relevant discipline.
- Experience in the coordination of a hospital Centers for Medicare and Medicaid (CMS), Department of Health (DOH, and/or Joint Commission (TJC) survey.
- Lean Six Sigma.
- Experience with tracer methodology and associated tools.
- Extensive knowledge of CMS Conditions of Participation for Hospitals, including Hospital-within-Hospital regulationstions
Job requires work after hours and/or weekends: Rare survey-related activity may occur on the weekend or after hours
Travel Expectations: Travel to all Fred Hutchinson Cancer Center locations for auditing, rounding, and survey purposes.
Astatement describing your commitment and contributions toward greater diversity, equity, inclusion, and antiracism in your career or that will be made through your work at Fred Hutch is requested of all finalists.
The annual base salary range for this position is from $104,416.00 to $165,006.40 and pay offered will be based on experience and qualifications.
Fred Hutchinson Cancer Center offers employees a comprehensive benefits package designed to enhance health, well-being, and financial security. Benefits include medical/vision, dental, flexible spending accounts, life, disability, retirement, family life support, employee assistance program, onsite health clinic, tuition reimbursement, paid vacation (12-22 days per year), paid sick leave (12-25 days per year), paid holidays (13 days per year), paid parental leave (up to 4 weeks), and partially paid sabbatical leave (up to 6 months).
