Accreditation and Policy Manager

Job Description

Job Description

Accreditation and Policy ManagerDepartment: Quality, Compliance & PrivacyProgram: Quality, Compliance & PrivacyReports To: Director of Quality, Compliance and PrivacyEmployment Status: Full TimeFLSA Status: ExemptSchedule: 40 Hours/WeekPreference: TERO Ordinance 2017-01, P.L. 93-638Job SummaryThe Accreditation and Policy Manager is responsible for the monitoring and maintaining the Kenaitze Indian Tribe's (the Tribes) policies, procedures, standard work, forms, Charters, Ordinances, and other documents. The Accreditation and Policy Manager ensures that all documents in the system are managed by responsible leaders in accordance with Federal, State, and accrediting bodies to maintain certification and licensure. Recommendations for documents will meet or exceed best practice principles, encouraging staff to provide quality and safe care for our patients/clients (un'ina). The Accreditation and Policy Manager will take a lead role in collaborating with department heads in maintaining continual compliance with Commission on Accreditation of Rehab Facilities (CARF) standards. Responsible for exploring and pursuing other accreditation, as appropriate, to ensure the Tribe maintains the highest possible service delivery standards.Essential FunctionsConducts regular monitoring, development and training of the policy management system.Collaborates with department managers providing education and guidance regarding effective development of documentsEnsures that all regulatory required documents remain active in the system and reflect changes imposed by the regulatory bodiesParticipates in and/or co-facilitates workgroup meetings for policy development and accreditation complianceCompletes and documents quarterly updates on the Annual Quality Assurance/Performance Improvement (QAPI) work planMaintains continual accreditation survey readiness by conducting mock surveys and audits, and developing corrective action plans to address any findingsCommunicates obstacles to Director of Quality, Compliance & Privacy in a timely manner. Prepares documents for external surveys/reviews, compliance plan and quality improvement plansCoordinates and delivers staff educationLeads policy and accreditation planning sessions with departments as neededStays current with healthcare regulations and standardsSeeks continuing education opportunities with the Institute for Healthcare Improvement (IHI), the National Association for Healthcare Quality (NAHQ) or any other professional organizations as applicableEnsures compliance with Tribal, federal, state, and local employment laws and regulations, Tribal policies and TERO ordinanceIt is the intent of this job description to highlight the essential functions of the position; however, it is not an all-inclusive list. The incumbent may be called upon and required to follow or perform other duties and tasks requested by his/her supervisor, consistent with the purpose of the position, department, and/or the Kenaitze Indian Tribe's objectivesWorking ConditionsLifting RequirementsSedentary work - Exerting up to 10 pounds of force occasionally, and/or a negligible amount of force frequently or constantly to lift, carry, push, pull or otherwise move objects, including the human body. Sedentary work involves sitting most of the time. Jobs are sedentary if walking and standing are required only occasionally, and all other sedentary criteria are met.Physical RequirementsStand or Sit (Stationary position)Walk (Move, Traverse)Use hands/fingers to handle or feel (Operate, Activate, Use, Prepare, Inspect, Place, Detect, Position)Stoop, kneel, crouch or crawl (Position self (to), Move)Talk/hear (Communicate, Detect, Converse with, Discern, Convey, Express oneself, Exchange information)See (Detect, Determine, Perceive, Identify, Recognize, Judge, Observe, Inspect, Estimate, Assess)Taste/Smell (Detect, Distinguish, Determine)Pushing or PullingRepetitive MotionOSHA CategoriesCategory III - Normal routine involves no exposure to blood, body fluid or tissue and as part of their employment, incumbents are not called upon to perform or assist in emergency care or first aidEquipment and ToolsList Equipment used for job:List Tools: Drives KIT or Personal Vehicle:TravelLocalIn -StateOut-Of- StateQualificationsEducationBachelor 's Degree in healthcare or related field, or a combination of education and experience may be substituted for a degreeExperienceTwo (2) years of experience in policy development or policy management in a healthcare settingTwo (2) years of experience leading a healthcare system to achieve successful accreditationLicense/CertificationMust have a valid Alaska State driver's license and must remain insurable under the Tribe's policySpecial SkillsProven ability to work on several projects simultaneously and under tight schedulesStrong interpersonal skillsExcellent problem-solving skillsExcellent writing skills with the ability to create business/healthcare documentsStrong knowledge of medical terminology and procedures to address nursing, medical, and BH provider issues related to policies, procedures, etc.Knowledge of Medicaid and National healthcare compliance regulations and practicesExperience with Survey prep for accrediting bodies such as CARF, AAAHC, etc.Conducts business in a service-oriented manner that is attentive, pleasant, respectful and kind when dealing with un'ina, visitors, co-workers and othersAbility to work independently as well as collaborativelyThis position is a Covered Position subject to all requirements of the Alaska Barrier Crimes Act (ABCA) and to the Indian Child Protection and Family Violence Prevention Act, (ICPA). ABCA and ICPA requirements apply and must be complied with at all times in order to remain in the position.