Providence Health & Services Regulatory and Accreditation Program Manager *$10,000 Sign-On Bonus* in Burbank, California
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Providence is calling a Regulatory and Accreditation Program Manager (Full time/Day Shift) to Providence Saint Joseph Medical Center in Burbank, CA.
This position is eligible for a $10,000 sign-on bonus for external candidates.
Please upload a current resume reflecting all relevant experience.
We are seeking a Regulatory and Accreditation Program Manager who will work in collaboration with the Director of Quality & Risk Management, the Regulatory & Accreditation Program Manager functions as support for compliance with accreditation standards, and state and federal regulations. Under the general supervision of the Director of Quality & Risk Management, the position manages functions to prepare the local Ministry continuum to meet external standards for accreditation, state and federal regulations.
The Manager is responsible to collaborate with the Quality, Risk and safety leaders/specialists to ensure compliance with accreditation standards, and state and federal regulations. The Manager will assist these areas in analyzing clinical processes, identify potential risks for patients and develop strategies to maximize safety, effectiveness and efficiency.
In this position you will:
Coordinate the CALS Survey (including The Joint Commission, CDPH, and IMQ) survey preparation and the facility survey process (pre-survey, during survey and post-survey)
Monitor changes in external standards; advocates for changes in standards and regulations, and coordinates the South Bay Community’s continuum preparations to meet new standards
Work collaboratively across the South Bay continuum to support compliance with standards, state and federal regulations and survey preparation
Provide planned education sessions to all levels of the organization on regulatory and licensure compliance
Prepare for surveys and inspections related to all regulatory agencies
Maintain the South Bay continuum minutes, action plans, and accreditation documents
Develop and maintain methods to share information across the South Bay continuum about standards, common issues and effective practices to meet standards, e.g., conference calls, web site, bulletin boards
In conjunction with the Director, partners with Medical Staff leadership, Medical Staff Office, and Administration to provide education to the Medical Staff on changes/new standards and regulations
Facilitate development of systems and processes to track action items related to regulatory compliance
Coordinate the activities of The Joint Commission Function Teams
Assist the department managers and organization leaders in compliance with new and revised standards
Facilitate development of comprehensive Joint Commission action item updates that are reported to the appropriate quality committee/council
Update organization-wide policies and procedures in accordance with changes in accreditation standards, laws and/or applicable regulatory agencies
Required qualifications for this position include:
CSHA (Certified Specialist in Healthcare Accreditation) required or must obtain within 1 year of hire
3 years experience in an acute care facility
2 years experience working with accreditation standards, and state and federal regulations
Demonstrates a working knowledge of The Joint Commission standards and regulatory related requirements, federal and state laws and regulations
Demonstrates working knowledge of the hospital and ambulatory information systems and other computer based communication and data base systems
Integrate effectively across various healthcare settings
Work efficiently and effectively in a matrix structured environment
Excellent verbal and written communication skills
Excellent problem solving skills
Quality and Safety
Change agent with positive approaches
Strong ability to lead and facilitate multi-disciplinary groups, develop effective teams
Prioritize and organize work in an accurate and timely manner
Process information and adapt quickly to a changing healthcare environment
Conduct multiple projects simultaneously
Promote a culture of transparency and openly discuss situations to be used as learning
Meet strict deadlines
Interact with regulatory officials, physicians, patients, and hospital personnel
Maintain good relations both inter and intra-departmentally
Preferred qualifications for this position include:
Bachelor's Degree in Nursing or Healthcare related field
Current California Registered Nurse License, or equivalent or higher level licensure
CPHQ (Certified Professional in Healthcare Quality
About the hospital you will serve.
Providence Saint Joseph Medical Center in Burbank, CA, is a 392-bed acute care facility founded over 75 years ago by the Sisters of Providence. Known for our state-of-the-art technology and high quality, compassionate care, we provide the full range of diagnostic, treatment, care and support services for the San Fernando Valley communities.
We provide many specialized services and treatment capabilities. Our Heart and Vascular center delivers care with one of Los Angeles County's first STEMI designated receiving centers for heart attack victims. The Hycy and Howard Hill Neuroscience Institute, which supports our Certified Comprehensive Stroke Center, continues to grow inpatient and outpatient programs addressing stroke, Parkinson’s, and brain tumors. Maternal Child Health Services, including a level 3 NICU, support whole family care with 24/7 on site labor support and community education. The Roy and Patricia Disney Family Cancer Center, a comprehensive, state-of-the-art, patient-centered, treatment facility. Our cancer center includes some of the most advanced technology in radiation oncology, highly advanced medical and surgical oncology providers, excellent clinical outcomes and research, and all patient support services are housed in the same building. Our exceptional orthopedic program has recognized for its excellent outcomes and clinical expertise. Our Bariatric Program, a leader and resource for those dealing with obesity in Southern California, received a Five-Star Rating for Bariatric Surgery. In the fall of 2022 we will open our brand new, state-of-the-art Emergency Department which will triple our capacity to care for the community in their time of greatest need.
We offer comprehensive, best-in-class benefits to our caregivers. For more information, visit
As expressions of God’s healing love, witnessed through the ministry of Jesus, we are steadfast in serving all, especially those who are poor and vulnerable.
Providence is a comprehensive not-for-profit network of hospitals, care centers, health plans, physicians, clinics, home health care and services continuing a more than 100-year tradition of serving the poor and vulnerable. Providence is proud to be an Equal Opportunity Employer. Providence does not discriminate on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law.
Job Category: Non-Clinical Lead/Supervisor/Manager
Req ID: 313095