Regulatory Compliance Manager - Phoenix, AZ

POSITION SUMMARY

The Regulatory Compliance Manager will monitor and maintain compliance to standards related to Joint Commission Accreditation, ADHS, OSHA requirements, and other regulatory agencies.  This position will identify opportunities for organizational and quality improvement and oversee the continuous quality improvement process throughout the organization. As a change leader, this position will mentor staff, align project management with Clinical Operations and the training department, and collaborate with People Service and Quality to ensure all quality standards are being met. 

EXPECTATIONS

Every Adelante Leader will strive to maximize the performance and contribution of each team member to Adelante Healthcare and the community that we serve every day.   Leaders will set clear performance expectations, provide on-going feedback and coaching to improve results and outcomes and provide regular performance evaluations.  Leaders are also expected to work in a manner that demonstrates a commitment to quality, patient safety, employee engagement, innovation and model for all other employees the highest standards of personal integrity, professionalism and competence.

OUR CORE VALUES

• Compassion
• Excellence
• Integrity
• Learning
• Respect
• Sustainability

ESSENTIAL SKILLS AND EXPERIENCE:

• Bachelor’s degree in the Healthcare field
• Minimum three (3) years’ of supervisory skills
• Minimum of five (5) years’ experience in Quality, Compliance, or related field in the healthcare industry
• Experience in managed care with knowledge of OSHA, ADHS, and The Joint Commission preferred
• Proficiency in developing and presenting analytic reports both written and verbal, data collection, sampling, analysis, and presentation
• Excellent working knowledge of Microsoft Office applications including Outlook, Word, Excel, SharePoint and Teams
• Must be able to write analytic reports integrating multiple data elements and perspectives
• Must be able to maintain confidentiality, privacy, and security of protected information
• Must possess excellent verbal and written communication skills, with the ability to communicate effectively with internal and external customers
• Valid Level One Fingerprint Clearance Card issued by the Arizona Department of Public Safety for all specialty behavioral health locations
• Certification to perform cardiopulmonary resuscitation for the Health Care Professional (CPR) and AED through courses that follow the guidelines from the American Heart Association and Red Cross (cognitive and skills evaluations)
• Comply with the organization's immunization requirements
• Travel to all health centers and community events is required
• Valid Arizona driver’s license and automobile insurance

POSITION RESPONSIBILITIES/ESSENTIAL:

• Create and foster working relationships with internal and external customers that facilitate accreditation/regulatory audits
• Establish, track, and achieve annual regulatory compliance goals in collaboration with the Director of Compliance and Training
• Plan and implement various special projects related to regulatory compliance
• Evaluate programs and recommend changes as necessary to improve programs and ensure compliance with regulatory requirements
• Develop and implement appropriate project management plans and tools to correct identified deficiencies
• Maintain knowledge of updated changes in TJC regulations, ADHS, OSHA and other regulatory requirements
• Maintain knowledge of updated changes in ADHS regulations Submits inter-cycle monitoring for TJC
• Provide oversight of all tracers including Medical, Dental, BH, Community Health, WIC, Front Office, OSHA and the JC Safer Matrix
• Complete gap analysis of JC, ADHS, OSHA, and other regulatory agencies regulation changes
• Monitor the online JC Tracer platform
• Collaborate with the Director of Compliance and Training on the development and implementation of the Regulatory Management Plan
• Collaborate with clinical operations leadership and training department as an expert in regulatory standards
• Collaborate with clinical operations leadership, facilities, and training and other departments on the development of action plans to correct deficiencies identified during internal audits
• Collaborate with the Quality department to create and update policies and procedures to ensure compliance with TJC,ADHS, OSHA  and other regulatory agencies
• Report TJC, HRSA, ADHS, and HRSA readiness to the Quality Committee, SLT, ELT and the Board of Directors
• Oversee the organization’s internal audit plan, including the development of tools, reporting and trending analysis.
• Collaborate with the Facilities department to review and update the AHC Environment of Care Plan
• Lead survey readiness preparedness activities including completion of the JC SAG, mock surveys and creating and providing survey readiness education
• Participate in the Safety Committee, P&T Committee and the Compliance Committee as needed 
• Participate in the SDOH Program and collaborates with key stakeholders on projects including action plans and reporting
• Attend annual Joint Commission conferences and/or Boot Camps
• Provide education during new hire orientation
• Work independently under the guidance of the Director of Compliance and Training
• Other projects as requested by the Director of Compliance and Training

NONESSENTIAL SKILLS AND EXPERIENCE:

• Ability to read and write in more than one language

Additional Duties and Responsibilities

• Other duties as requested or assigned

PCMH

All employees are responsible for promoting and participating in interdisciplinary communication and collaboration to enhance the delivery of quality across the health care system. Employees should maintain an environment which supports and engages patients and co-workers in a caring team based model to promote wellness and improve health outcomes.

Adherence to Compliance and Code of Conduct

All employees are required to comply with Adelante Healthcare’s written standards, including its Compliance Program and Standards of Conduct, policies and procedures and reporting of any conduct that potentially violates Adelante’s legal or compliance requirements. Such compliance will be an element considered as part of the regular performance evaluation.

PHYSICAL DEMANDS AND WORK ENVIRONMENT

The physical demands and work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Physical demands: While performing the duties of this job, the employee may be required to sit for long periods of time, is required to stand, walk, use hands to handle or feel objects, tools or controls; reach with hands and arms; climb steps/stairs; balance; stoop, kneel, crouch or crawl; talk or hear; smell; manage stress as it relates to essential job functions.  The employee must frequently lift and/or move up to 25 pounds without assistance, and may occasionally be required to lift or move up to 50 pounds with assistance.  Specific vision abilities required by the job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus.

Work environment:   While performing the duties of this job, the employee is exposed to weather conditions prevalent at the time when traveling to various clinic sites.  The noise level in the work environment is usually moderate. The employee may be subject to health hazards (contagious diseases, blood borne pathogens, etc.) when working in the clinic area.