Full-Time AR & L Director

This position supports Kaiser Permanente’s code of conduct and compliance by adhering to all laws and regulations, accreditation and Licensure requirements, and internal policies and procedures. Kaiser Permanente is an AA/EEO employer. DEPARTMENT: Survey Accred Prep SCHEDULE: Full-time regular; 40hrs/week; Shift: Day; 8:30am-5:00pm; Monday-Friday EDUCATION: Bachelors degree in health care administration, nursing, or public administration or related field required.  Other clinical licensure or Master's Degree in related field required.   CERTIFICATION/LICENSE: Total Quality Management certification or Certified Professional of Healthcare Quality (CPHQ) preferred; Other clinical licensure or Master's Degree in related field required.   REQUIRED SKILLS TESTING:  N/A POSITION SUMMARY: Directs the Medical Center’s operations and activities to comply with all accreditation, regulation, and licensing requirements for all health care sites and services across the continuum including, but not limited to: home health, ambulatory services, provider networks, hospital services and health plan.  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 standards and to implement new processes to meet new requirements. QUALIFICATIONS/EXPERIENCE:  Experience designing, developing, implementing clinical improvement programs.  Significant experience (usually 5 years) in Quality Improvement in a health care setting.  Previous management experience required.  Demonstrated knowledge of governmental and other regulatory standards, requirements, and guidelines related to quality improvement, such as The Joint Commission, NCQA, Knox-Keene Act, Federal HMO Act, CMS Conditions of Participation, Title 22, Cal-OSHA, HIPAA  and Medi-Cal and Medicare regulations and standards.  Strong working knowledge of ongoing monitoring techniques (including criteria development and statistical analysis); medical care delivery in hospital and outpatient settings; total quality management principles, tools, and techniques.  Effective communication, negotiation and leadership skills.  Must be able to work in a Labor/Management Partnership environment.  Preferred Qualifications: Previous management experience in nursing or other allied health professional experience preferred. DUTIES: Directs the Medical Center’s operations and activities to comply with all licensing and accreditation standards and requirements, ensuring consistency with organizational goals and priorities.  Works closely with designated Chiefs of Service and Department Managers to ensure that principles of confidentiality and responsibility are adhered to. Determines strategy for changing existing processes to meet regulatory requirements and translating external demands into program goals. Provides education and technical support to the Medical Center in developing, implementing and maintaining regulatory compliance.  Partners with Risk Management to reduce medical/legal liability through development of a program which links risk management activities with those of regulatory compliance.  Serves as a critical link in the identification and resolution of issues, which affect organizational image.  Develops and maintains relationships and effective communication with all levels of medical center physicians and staff in order to facilitate problem identification and resolution.  Manages staff and makes recommendations regarding the need for staff, space and other resources.  Manages and resolves human resources and labor relations issues specific to management responsibilities.  Develops systems, templates, tools and processes to identify and monitor indicators which best measure improvement in care delivery. Analyzes, interprets and makes recommendations to meet federal, state and local requirements.  Identifies key accreditation, regulation and licensing issues and defines areas for improvement. Establishes mechanisms for pro active identification of regulatory issues and tracking of corrective action to minimize negative impact and maximize learning. Relays internal/external communication of information related to accreditation, regulation and licensing.  Partners with the Quality Director to prepare for surveys and inspections, including educational forums, coordinating mock surveys and assessments assists in developing response plans.  Coordinates formal surveys for all regulatory and accrediting agencies. Interprets and assists in planning responses to new or changing regulations or standards.  Collaborates with external regulators to develop standards that promote high quality patient care and services.  Serves as liaison to region, community groups, professional organizations, and licensing/regulatory agencies.  Develops, implements, and meets the established financial goals.  Monitors applicable budget; and identifies and supports solutions to reduce cost structure. Consistently supports compliance and the Principles of Responsibility (Kaiser Permanente’s Code of Conduct) by maintaining the privacy and confidentiality of information, protecting the assets of the organization, acting with ethics and integrity, reporting non-compliance, and adhering to applicable federal, state and local laws and regulations, accreditation and licenser requirements (if applicable), and Kaiser Permanente’s policies and procedures. Kaiser Permanente conducts compensation reviews of positions on a routine basis.  At any time, Kaiser Permanente reserves the right to reevaluate and change job descriptions, or to change such positions from salaried to hourly pay status.  Such changes are generally implemented only after notice is given to affected employees.  For more information, please contact Shannon Kelly at (925) 295-6497 or e-mail at Shannon.M.Kelly@kp.org Additional Information Reference Code: OA.0700763 Position Type: Full Time, Employee Contact Information Shannon Kelly Apply by Email Kaiser Permanente - Northern California