Accreditation and Policy Manager

Accreditation and Policy Manager Department: Quality, Compliance and Privacy Program: Quality, Compliance and Privacy Reports To: Director of Quality, Compliance and Privacy Employment Status: Full Time FLSA Status: Exempt Schedule: 40 Hours/Week Preference: TERO Ordinance 2017-01, P.L. 93-638 Job Summary The Accreditation and Policy Manager is responsible for the monitoring and maintaining the Kenaitze Indian Tribe's (the Tribes) policies, procedures, standard work, forms, Charters, Ordinances, and other documents. The Accreditation and Policy Manager ensures that all documents in the system are managed by responsible leaders in accordance with Federal, State, and accrediting bodies to maintain certification and licensure. Recommendations for documents will meet or exceed best practice principles, encouraging staff to provide quality and safe care for our patients/clients (un'ina). The Accreditation and Policy Manager will take a lead role in collaborating with department heads in maintaining continual compliance with Commission on Accreditation of Rehab Facilities (CARF) standards. Responsible for exploring and pursuing other accreditation, as appropriate, to ensure the Tribe maintains the highest possible service delivery standards. Essential Functions - Conducts regular monitoring, development and training of the policy management system.Collaborates with department managers providing education and guidance regarding effective development of documents - Ensures that all regulatory required documents remain active in the system and reflect changes imposed by the regulatory bodies - Participates in and/or co-facilitates workgroup meetings for policy development and accreditation compliance - Completes and documents quarterly updates on the Annual Quality Assurance/Performance Improvement (QAPI) work plan - Maintains continual accreditation survey readiness by conducting mock surveys and audits, and developing corrective action plans to address any findings - Communicates obstacles to Director of Quality, Compliance and Privacy in a timely manner. Prepares documents for external surveys/reviews, compliance plan and quality improvement plans - Coordinates and delivers staff education - Leads policy and accreditation planning sessions with departments as needed - Stays current with healthcare regulations and standards - Seeks continuing education opportunities with the Institute for Healthcare Improvement (IHI), the National Association for Healthcare Quality (NAHQ) or any other professional organizations as applicable - Ensures compliance with Tribal, federal, state, and local employment laws and regulations, Tribal policies and TERO ordinance It is the intent of this job description to highlight the essential functions of the position; however, it is not an all-inclusive list. The incumbent may be called upon and required to follow or perform other duties and tasks requested by his/her supervisor, consistent with the purpose of the position, department, and/or the Kenaitze Indian Tribe's objectives Working Conditions Lifting Requirements Sedentary work - Exerting up to 10 pounds of force occasionally, and/or a negligible amount of force frequently or constantly to lift, carry, push, pull or otherwise move objects, including the human body. Sedentary work involves sitting most of the time. Jobs are sedentary if walking and standing are required only occasionally, and all other sedentary criteria are met. Physical Requirements Stand or Sit (Stationary position) Walk (Move, Traverse) Use hands/fingers to handle or feel (Operate, Activate, Use, Prepare, Inspect, Place, Detect, Position)