Manager Of Accreditation & Licensing

Kaiser Permanente Fontana , CA 92334

Posted 3 months ago


Provides consultation and supports activities related to licensure, accreditation, and regulatory compliance within the Medical Center Service Area. Responsibilities include researching and staying abreast of existing, new, emerging, and revised regulations, statutes, and accreditation standards.

Facilitates continuous compliance of, preparation for, and follow up responses for all surveys such as GACH, The Joint Commission, California Department of Public Health, Medicare & Medicaid Services, California Children's Services, NCQA, College of American Pathologists, etc. Collaborates with administrators, managers, and physician leaders to assist with and coordinate regulatory compliance efforts, continuous survey readiness, and survey preparation. Ensures that all areas of vulnerability related to licensure, accreditation, and regulatory compliance are identified. When coordinating plans, works with appropriate individuals and/or teams.

Essential Responsibilities:

Serves as the primary internal contact for all licensure, regulatory and accreditation agencies.Provides expert consultative services to all KFH/HP and SCPMG departments and services regarding intent and application of regulations/standards, and effective strategies, programs and tactics to attain and maintain compliance.Continually appraises analyses and interprets changes in legislation and requirements related to regulatory accreditation and licensure issues.Maintains and provides oversight of the Service Area Administrative Policy Manual as designated by the Board of Directors.Assures continuity and consistency in compliance with regulatory issues across the organization by evaluating the impact of specific issues.Collaborates with appropriate departments to develop and implement corrective action to minimize negative impact and maximize learning.Conducts frequent tracer rounds.Identifies key accreditation, regulation and licensing issues and defines areas for improvement.Collaborates and coordinates with departments on any implementation and evaluation of legislation affecting the Service Area.Provides overall staff support to the Accreditation and Licensing Committee such as to coordinate activities and agenda, and action plans, and to provide research analysis and recommendations for issues.

Basic Qualifications:


Minimum three (3) experience in health care.


Bachelor's degree in Health Care Administration, Public Health, Nursing or four (4) years of experience in a directly related field.High School Diploma OR General Education Development (GED) required.

License, Certification, Registration


Additional Requirements:

Expertise in applicable federal and state laws, regulations and standards, such as TJC, NCQA, EMTALA, CMS CoPs, DMHC, Medi-Cal, and Medicare regulations, interpretations and rulings. Demonstrated experience in statistical analysis and quality management processes.

Excellent oral and written communication skills.

Preferred Qualifications:

One (1) year Supervisory experience preferred. Clinical experience and clinical operations management preferred.

Ability to engage others, build teams and foster an internal culture of continuous survey readiness and compliance preferred.

Ability to effectively translate legal provisions and industry standards into practical applications processes and procedures preferred. Skills in Policy/Procedure development, review, analysis, revision and document retention preferred.

Demonstrated ability to navigate through statutes, regulations, standards, as well as recommendations and guidelines from nationally recognized organizations such as the Centers for Disease Control and Prevention (CDC), the Association for Professionals in Infection Control and Epidemiology (APIC), the Association for the Advancement of Medical Instrumentation (AAMI), the Association of perioperative Registered Nurses (AORN), the National Fire Protection Association (NFPA), the U.S. Occupational Health and Safety Administration (OSHA) Technical Manuals, to determine applicability, commonalities, enforcement, and to develop a comprehensive, cohesive approach to compliance.Master's degree preferred.Regulatory knowledge (Title 22, CMS, and TJC), clinical experience.

Primary Location: California,Fontana,Fontana Medical Center (replacement) 9961 Sierra A Scheduled Weekly Hours: 40 Shift:

Day Workdays: Mon, Tue, Wed, Thu, Fri Working Hours Start: 8:00 AM Working Hours End: 5:00 PM Job Schedule: Full-time Job Type:

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

Entry Level Job Category: Compliance / Privacy / Regulatory Department: Accreditation & Licensing Travel:

Yes, 25 % 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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Manager Of Accreditation & Licensing

Kaiser Permanente