Accreditation, Regulatory, and Licensing Specialist VI, Clinical (KFHP/H)

In addition to the responsibilities listed above, this role is also responsible for: guiding others to schedule and perform the site reviews, medical record reviews, and Physical Accessibility Review (PAR) surveys; independently conducting highly complex site visits for ambulatory care and affiliated sites, as needed; driving the creation, planning, and enactment of strategy to ensure survey performance is in accordance with all regulatory requirements via rounds with staff, leaders, and providers; building educational highly 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, independently; serving as a consultative resource for highly complex regulatory and accreditation programs recommendations, relevant program practice guidelines, order sets; leading the planning and execution of long-term Ambulatory Surgery Centers/Units (ASCs or ASUs) quality and patient safety priorities, in alignment with regional and organization-wide goals; serving as an internal expert resource for aid in development and implementation of 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; leading others to support Graduate Medical Education (GME) for non-physician roles (Hospital Markets Only); independently communicating regulatory, policy, patient safety and quality program status and issues to program leads, business owners, and leadership; proactively defining high-impact issues and providing consultative expertise for regulatory and accreditation programs recommendations, relevant program practice guidelines; and coordinates and maintains clinical and service quality improvement activity summaries for regulatory oversight bodies.

• Promotes learning in others by communicating information and providing advice to drive projects forward; builds collaborative, cross-functional relationships. Solicits and acts on performance feedback; provides actionable feedback to others, including upward feedback to leadership; influences, mentors, and coaches team members. Practices self-leadership; creates, evaluates, and responds to the strengths and weaknesses of self and unit or team members. Leads the adaptation to competing demands and new responsibilities; adapts to and learns from change, challenges, and feedback. Fosters open dialogue amongst team members.


• Drives the execution of multiple work streams by identifying member and operational needs; translates business strategy into actionable business requirements; develops and updates new procedures and policies. Gains cross-functional support for objectives and priorities; determines and carries out processes and methodologies; solves highly complex issues; escalates and resolves issues as appropriate; sets standards and measures progress. Develops work plans to meet business priorities and deadlines; coordinates, obtains and distributes resources. Removes obstacles that impact performance; guides performance and develops contingency plans accordingly; influences the completion of project tasks by others.


• Serves as the subject matter expert for regulations projects/committees, and internal stakeholders by: providing consultation on the interpretation and interaction of current policies, and how they interact with the current climate, and potential changes to regulations and legislation; serving as a senior technical advisor on committees and projects to drive development of policies or procedures for regulations and auditing processes; developing highly complex content and delivering tailored educational programs to align organizational policies and procedures with regulatory requirements; and anticipating and weighing practical/technical considerations in addressing issues and coordinating with the appropriate stakeholders to develop resolutions.


• Develops data management and reporting processes by: entering complex practitioner/provider data and conducting data cleaning as needed; and analyzing, independently drafting, reviewing, and evaluating action plans/recommendations required data into appropriate databases.


• Ensures licensing and accreditation by: guiding implementation of changes and leading the review of 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 highly complex cases; and leading conduction of a widely impactful, detailed, and complex gap analysis and mentoring others to identify services renewals and planning to ensure services are compliant.


• Identifies and recommends improvements to processes of responding to regulatory audits and survey preparedness efforts by: independently enacting highly complex reporting, keeping current on regulatory requirements, and guiding others to do the same in preparation for surveys (e.g., NCQA, Joint Commission, AAAHC); serving as the liaison between applicable government, regulatory, and key stakeholders for on-site visits and evaluations; assisting in development of, conducting, reviewing, evaluating upon site visit criteria, performing site visits as appropriate to ensure survey readiness; delivering requested complex audit documentation, information, and reports; assessing the workflow of auditing surveys and connecting with stakeholders to identify gaps in completion and reporting, focusing on high vulnerability areas; facilitating educational forums, conducting routine audits, and leading mock surveys within departments to ensure auditing and survey preparedness tracking, trending, and facilitating the development of high impact corrective action plans (CAP) as necessary in collaboration with applicable departments to assure site visit compliance; and leading the collaborations with other departments, gathering documents and data (e.g., Revenue Cycle) to support and plan for the timely completion and of the annual state/federal/regulatory body reporting as required.