At UC Health, we're proud to have the best and brightest teams and clinicians collaborating toward our common purpose: to advance healing and reduce suffering.

As the region's adult academic health system, we strive for innovation and provide world-class care for not only our community, but patients from all over the world. Join our team and you'll be able to develop your skills, grow your career, build relationships with your peers and patients, and help us be a source of hope for our friends and neighbors.

UC Health is committed to providing an inclusive, equitable and diverse place of employment

Under the supervision of the Enterprise Director of Regulatory and Accreditation, the Manager of Accreditation, Regulatory Compliance and Campus Integration manages and coordinates the organizational effort to assure continuous compliance with Joint Commission standards, CMS Regulations and any other regulatory bodies. Project manages campus integration including hospital based ambulatory care.

Accreditation and Regulatory Compliance - 50%

• Serves as the organizational resource on interpretation of Joint Commission standards,
• CMS Conditions of Participation and ODH by developing and maintaining expert knowledge
• Manages, coordinates and directs operational and patient care services in ongoing survey readiness.
• Serves at the organization liaison to UC Health Corporate Compliance department. Assists them with the development of auditing priorities, action plans and ongoing audits to ensure compliance. Develops regulatory reports to be presented to UC Health Governing Body.
• Provides education and collaboration to hospital departments and managers to assure current knowledge of appropriate standards.
• Designs, organizes and implements systems for tracking, evaluation and reporting efforts and outcomes relative to standards set by accrediting and regulatory agencies.
• Assures continuous readiness thru ongoing evaluation of compliance.
• Provides reports and feedback to Senior Leadership regarding readiness status including timely reports of gaps or potential gaps in readiness.

Project Management for Campus Integration - 40%

• Responsible for the project management of campus integration including hospital based ambulatory care.
• Chairs weekly meeting with hospital ambulatory care practice leadership to address any opportunities in the on-boarding process and transition.
• Establish priorities that align with UC Health's current direction and need.
• Contribute to the management of organizational changes and operational processes.
• Direct individuals and departments in the establishment, implementation and stabilization of new services and processes.
• Work closely with and reports to Senior Leadership to monitor the progress to ensure regulatory compliance from all aspects of TJC, CMS, ODH and Ohio Board of Pharmacy.
• Independently coordinate projects of high complexity.

Education and Communication - 10%

• Provides education and mentoring to managers, staff and physicians to assure attainment of program goals.
• Conducts audits to ensure regulatory compliance.
• Develops and reports effective outcome measures for the regulatory compliance program.
• Coordinates Physician annual education to ensure regulatory compliance. Utilizes diverse communication and education strategies to assure the integration of regulatory compliance practices by all staff, volunteers and physicians utilizes systems thinking to identify causes and solution to errors.
• Utilizes statistical processes and uses dynamic data displays to provide information to front line care givers in a timely manner.

Minimum Requirement: Bachelor's Degree in Nursing is required. Current RN License. Minimum Requirement: 3 - 5 Years equivalent experience.

Preferred: Master's Degree. 5 years clinical experience preferred in multiple areas plus 2 years of line or project management experience. Preferred: 3 - 5 Years equivalent experience in clinical data analysis experience in hospital/health care setting preferred. Formal training or experience in patient safety preferred.