Job Description

As a patient-focused organization, University of Utah Health exists to enhance the health and well-being of people through patient care, research and education. Success in this mission requires a culture of collaboration, excellence, leadership, and respect. University of Utah Health seeks staff that are committed to the values of compassion, collaboration, innovation, responsibility, integrity, quality and trust that are integral to our mission. EO/AA

This position coordinates the regulatory activities of the Hospitals and Clinics to meet the requirements of multiple regulating agencies for accreditation. This position is not responsible for providing care to patients.

Corporate Overview: The University of Utah is a Level 1 Trauma Center and is nationally ranked and recognized for our academic research, quality standards and overall patient experience. Our five hospitals and eleven clinics provide excellence in our comprehensive services, medical advancement, and overall patient outcomes.

Responsibilities

Essential Functions

• Serves as the organizational expert for DNV, ISO 9001, State and CMS CoP regulations.
• Leads a coordinated response to announced and unannounced external accrediting or regulatory agency visits such as CMS, DNV, CARF, or DHHS.
• Analyzes reports and data such as regulatory surveys and investigations; facilitates corrective action plans (CAP) and plans of correction (PoC) with managers/directors.
• Researches and analyzes DNV, ISO 9001, State, CMS Conditions of Participation (CoPs), and other regulatory agency requirements and standards.
• Responsible for the interpretation and communication of regulatory requirements throughout the organization. Stays current with new standards and can present to large groups, teams, or Senior Leadership.
• Provides education, training, and consultation to administrative and clinical leadership, staff, and faculty throughout the organization regarding the requirements of accreditation and regulatory organizations.
• Provides guidance and assistance to service lines, departments, and units regarding improvements needed to monitor and ensure compliance with regulations and standards.
• Provides timely communication regarding new and revised federal, state, and local regulations, standards, and interpretations to administrative and clinical leadership, staff, and faculty.
• Facilitates the development of tools, policies, procedures, and learning aids to promote compliance with standards.
• Builds effective, supportive, productive relationships with leadership, staff, and faculty.
• Manage documented information for hospitals and clinics documents and policies.
• Facilitates quality improvement activities as directed.
• Active participant in the Internal Audit Program and collaborates with operational managers and directors.
• Participates in patient safety improvement work or teams as directed.

Knowledge / Skills / Abilities

• Ability to perform the essential functions of the job as outlined above.

• Demonstrates knowledge of DNV, ISO 9001, CMS Conditions of Participation, and other regulatory agency requirements.

• Ability to effectively assist the hospitals and clinics in preparation for regulatory surveys by communicating all necessary information to the appropriate departments and recommending actions to maintain compliance.

• Outstanding team player and helps build teams.

• Ability to develop effective relationships with a broad array of people with various backgrounds.

• Superior organizational skills to manage a large volume of incoming data, information, reports, etc.

• Ability to create and deliver appealing and compelling presentations to various audiences, including clinicians, staff, faculty, administration, and governance groups.

• Excellent written and verbal communication skills.

• Demonstrates skill in change management and quality improvement.

• Knowledge of clinical/medical terminology.

• Strong computer skills including Microsoft Office platform—Teams, Word, Excel, PowerPoint, E-mail, Web/Internet.

• Ability to learn and effectively use computer software, such as electronic health records and data entry.

• Flexibility in work schedule.

• Ability to have collaborative, objective investigative skills to perform audits.

• Able to work independently and function effectively in a team setting

Qualifications

Required

• Bachelor's degree required in a health care related fields such as nursing, laboratory, public health, healthcare administration or other fields that support the health care business or equivalent experience.
• Three years experience in a healthcare setting or as a provider of services to the healthcare industry.

Qualifications (Preferred)

Preferred

• ISO Internal Auditing experience.
• Master's degree in a health-related field.
• Lean and Six Sigma knowledge.
• Project Management experience.
• ISO 9001 knowledge.
• Two years of work experience in regulatory accreditation such as CMS, DNV, Joint Commission, or DHHS.
• One year of work experience in behavioral health.
• Current RN license.

Working Conditions and Physical Demands

Employee must be able to meet the following requirements with or without an accommodation.

• This is a sedentary position that may exert up to 10 pounds and may lift, carry, push, pull or otherwise move objects. This position involves sitting most of the time and is not exposed to adverse environmental conditions.

Physical Requirements

Carrying, Color Determination, Listening, Manual Dexterity, Sitting, Speaking, Standing, Walking