Position Summary: To provide administrative leadership and act as a liaison from Miller Children and Woman’s Hospital Long Beach (MCWHLB) Long Beach Memorial (LBM)) to Licensing and Accreditation Agencies. This position includes analyzing clinical, organizational and operational systems to identify areas in need of improvement, control or change to assure compliance with accreditation/regulatory standards. The individual will coordinate state licensure applications, license renewals, occupancy surveys, and development and implementation of corrective action plans for resolving any identified deficiencies. Periodic reports regarding compliance gaps will be reported to leadership, hospital/system committees and the medical staff. In addition, this position ensures licensing and accreditation compliance for MCWHLB and LBM, and coordinates with California Department of Health Care Services (CDHCS), California Department Public Health (CDPH), California Children’s Services (CCS), California Children’s Hospital Association (CCHA) and other agencies and organizations to assure that new programs and services developed meet regulatory requirements.
Principal Duties and Responsibilities:
Essential Job Functions – General Accountabilities
Demonstrates high level of attention to detail and provides supporting documentation for all reports, regulatory filings and projects using tracking grids and monitoring tools consistently.
Responsible for ongoing monitoring and communication of new and existing regulatory requirements (state and/or federal) and prepares summaries for management as needed.
Demonstrates capability to handle multiple projects and tasks simultaneously, using project management tools to oversee status of all pending department/organization projects.
Maintains an updated Resource Library of related materials that is available electronically to all Senior Executives, Vice Presidents, and Executive Directors.
Assess the educational needs and develops training for hospital leaders related to licensing, program flex, regulatory waivers, accreditation standards, or other areas as assigned.
Acts as organization wide consultant for Regulatory Standards including but not limited to JC, CMS, CCS, CDPH, Licensing and Certification and Title 22.
Coordinates and acts as the contact liaison on all activities related to CDHCS,CDPH, CCS and other regulatory agencies for the Long Beach campuses (LBM, MCWHLB)
Coordinates organization wide certification and licenses for hospital, pharmacy, lab and radiology and others as identified.
Collaborates with facilities leadership on any new construction projects requiring approvals by licensing and certification agencies.
Acts as a consultant and liaison to the CDHCS in determining need for clinical and facility program flex and works with leaders on application and filing process.
Ensure that all regulatory reports, licenses, amendments and required notifications are on tracking schedules for timely renewal and notification of appropriate leaders.
Research and prepares recommendations on new state and federal requirements, providing summary reports to leadership for decision making.
Collaborates with and maintains rapport and relationships with personnel of licensing and regulatory entities to further organization strategic goals and objectives and protect the reputation of MemorialCare.
Acts as organization wide consultant for Regulatory Standards interpretation including but not limited to CDPH Licensing and Certification, Title 22, Joint Commission, CMS, and California Children’s Services.
Guides and actively participates in assuring compliance with California Children’s Service’s Standards and coordinates the CCS site visits, involving appropriate leadership at MCWHLB and LBM.
Participates in survey readiness activities for Joint Commission, CMS, GACHRLS, and CCS and designs education necessary for hospital and clinic staff.
Coordinates the development, submission, implementation and monitoring of corrective action plans related to identified deficiencies.