Director, Accreditation, Credentialing, Risk & Patient Safety

Kaiser Permanente Atlanta , GA 30301

Posted 3 weeks ago


Promotes the delivery of reliable, effective, consistent and safe care and service for all members in all venues in partnership with key operational stakeholders. Responsibilities include: developing a region-wide plan for routine quality and safety surveillance, developing interventions and programs to target identified opportunities to improve quality and efficiency of care and service and monitoring and reporting meaningful indicators and outcomes that guide continuous improvement.

Ensures Quality Program complies with external accrediting and regulatory bodies and internal quality review processes. Provides direct management oversight of program including credentialing and peer review activities. Ensures that all aspects of the department are run efficiently and effectively.

Directs operations and activities to comply with all accreditation, regulatory, and licensing requirements for all the Kaiser Permanente Georgia health care facilities and affiliated health care organizations. 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 standard and implement new processes to meet new requirements.

Essential Responsibilities:

Ensure Kaiser Permanente Georgia complies with all licensing and accreditation standards. Determine the strategy for changing existing processes to meet regulatory requirements and translating external demands into program goals. Develop systems, templates, tools and processes to identify and monitor indicators which best measure improvement in care delivery in regards to accreditation requirements and disease management programs.

Partner with other departments to reduce medical/legal liability through development programs that link risk management activities with those of regulatory compliance. Work closely with designated Risk/Safety physicians.

Analyze, interpret and make recommendations to meet federal, state and local requirements. Establish mechanisms for proactive identification of regulatory issues and tracking of corrective actions.

Identify key accreditation, regulation and licensing issues and define areas for improvement. Collaborate with Compliance as applicable.

Analyze, interpret and make recommendations to meet federal, state and local requirements and as applicable collaborate with Compliance and Legal departments. Establish mechanisms for proactive identification of regulatory issues and tracking of corrective actions.

Identify key accreditation, regulation and licensing issues and define areas for improvement.

Develop and maintain relationships and effective communication with all levels of physicians and staff in order to facilitate problem identification and resolution. Relay internal/external communications of information related to accreditation, regulation and licensing.

Provide direction and oversight in the development, planning and execution of short and long term Quality and Safety priorities and strategies in alignment with regional and organization-wide goals.

Establishes clear and measurable short and long-term strategic goals and objectives and monitors results. Keeps abreast of industry/regulatory trends. Ensures quality and patient safety strategies are aligned with regional business strategies.

Accountable for ongoing quality program compliance with regulatory and accrediting agencies and review bodies including: National Committee for Quality Assurance (NCQA), Center for Medicaid and Medicare Service (CMS - including the Medicare Modernization Act MMA), Department of Human Resources (DHR), Medical Directors' Quality Review (MDQR), Quality Health Improvement Committee (QHIC). Ensures all activities which support the implementation of the Quality, Patient Safety related to members and practitioners comply with regulatory and accreditation requirements.

Supervises and mentors staff with regard to job performance and professional development.

Partner with department chiefs and operations managers to develop department-specific quality interventions to improve quality and patient safety.

Develop and implement a regional patient safety strategy that includes a region-wide plan for routine surveillance of quality and patient safety systems, including hospitals and other contracted organizations and practitioners.

Identify routine patient safety and continuity of care metrics for each department.

Supports chiefs in the review of quality and patient safety concerns identified through peer review, near miss reporting and member concerns including: Review aggregate data on a routine basis and conduct root cause analysis of identified issues as needed; partner with Chiefs and operational leaders to prioritize issues and develop action plans to address them; document action plans and monitor results as required by regulatory and accreditation bodies.

Board of Director's Audit: Accountable for maintaining compliance with BODA standards (current and future). Understand intent of each standard and requirements needed to meet the intent; track future requirements, anticipate activities necessary to become compliant, and take necessary steps to ensure compliance, manages BODA self-assessments and on-site surveys.

Partners with Corporate Risk Management in the reporting of information, address all follow-up items in collaboration with appropriate departments to close the loop on identified outstanding/follow-up items. Identify and transfer best practices for improving quality and patient safety.

Responsible for budget planning and annual budget preparation, managing the budget, and budget tracking for all Departmental accounts.

Participate in cross-functional teams to improve quality and effectiveness of care delivery.

Responsible for assessing performance and monitoring outcomes in areas of Departmental responsibility.

Support operational leaders in the further integration of quality and safety to optimize the operating structure and create seamless clinical integration throughout the organization.

Leads by demonstrating exemplary interpersonal skills that translate into positive relationships with colleagues and clients.

Basic Qualifications:


Minimum ten (10) years relevant experience in a health care setting.

Minimum five (5) years of management experience and demonstration of quality improvement, safety and risk management experience.


Bachelor's degree in nursing, health care, business administration or in a directly related field.

License, Certification, Registration


Additional Requirements:

Experience designing, developing, and implementing clinical improvement programs.

Experience in government and regulatory standards, requirements, and guidelines related to quality improvement, such as The Joint Commission, NCQA, and Medicare regulations and standards.

Experience leading or participating in accreditation activities such as NCQA or other regulatory programs.

Strong working knowledge of ongoing monitoring techniques including criteria development and statistical analysis.

Knowledge of medical care delivery in a hospital and outpatient setting.

Knowledge of total quality management principles, tools, and techniques.

Excellent communication, negotiation and leadership skills.

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

Significant experience working with physicians and other health care professionals.

Experience leading quality improvement teams, clinical risk and safety systems management, credentialing and accreditation.

Experience working in a partnership with multiple constituents throughout an organization. This includes achieving consensus through presentations, thought leadership, partnership, and relationship building throughout the organization.

Working knowledge of all applicable standards and requirements of regulatory, accreditation, and licensing agencies.

Experience in successfully managing quality performance improvement, accreditation and data analysis in a complex hospital or patient care delivery system.

Competent in statistical and data analysis, experience with data repositories, registries and/or warehouses helpful.

Knowledge of national trends and key issues related to quality, performance improvement and patient safety.

Working and applied knowledge of a performance improvement methodology such as LEAN, Six Sigma.

Has built and mentored a high performing team and has shown the ability to foster internal growth of team members through professional education and developmental opportunities.

Preferred Qualifications:

Minimum ten (10) years of progressive leadership experience in a large complex hospital or health system.

Master's degree in health care, business administration, or related field is required.

Certified Professional in Health Care Quality preferred.

Certified Safety Professional preferred.

Certified Risk Manager preferred.

Certified Credentialing Specialist preferred.

Primary Location: Georgia,Atlanta,Regional Office -11 Piedmont 11 Piedmont Center 3 Scheduled Weekly Hours: 40 Shift:

Day Workdays: Mon, Tue, Wed, Thu, Fri, Working Hours Start: 8:00 AM Working Hours End: 4:00 PM Job Schedule: Full-time Job Type:

Standard Employee Status: Regular Employee Group/Union Affiliation: Salaried, Non-Union, Exempt Job Level:

Director/Senior Director Job Category: QA / UR / Case Management Department: Quality Department 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.

Click here for additional requirements >

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Director, Accreditation, Credentialing, Risk & Patient Safety

Kaiser Permanente