Director of Accreditation & Regulatory Affairs

Job Description Summary

The Charleston Director of Regulatory Affairs / Accreditation (Charleston) reports to the MUSC Health Charleston Chief Quality Officer (CQO) and the Director for Regulatory Affairs/Accreditation (System). Under direct supervision, the Director ensures the daily operations of MUSC Health Charleston are conducted in accordance with hospital, system, and departmental policies and procedures, safety guidelines, and regulatory standards. This position educates team members on regulatory requirements and ensures compliance with regulations, in addition to working strategically with the CQO and System Director to develop a Division Accreditation strategy.

Entity

Medical University Hospital Authority (MUHA)

Worker Type

Employee

Worker Sub-Type​

Regular

Cost Center

CC000649 CHS - Quality Management

Pay Rate Type

Salary

Pay Grade

Health-35

Scheduled Weekly Hours

40

Work Shift

Day (United States of America)

Job Description

The Regulatory Affairs / Accreditation Manager (Charleston) reports to the MUSC Health Charleston Chief Quality Officer (CQO) and the Director for Regulatory Affairs/Accreditation (System). Under direct supervision, the Manager ensures the daily operations of MUSC Health Charleston are conducted in accordance with hospital, system, and departmental policies and procedures, safety guidelines, and regulatory standards. This position educates team members on regulatory requirements and ensures compliance with regulations, in addition to working strategically with the CQO and System Director to develop a Division Accreditation strategy.

A Master’s degree and minimum ten (10) years relevant leadership experience in regulatory associated programs in a complex academic or medical center setting. Certification as a Joint Commission Professional is preferred. Have ability to respond to surveys and inspections in a timely and professional manner. Experience with regulatory compliance software preferred. Strong organizational, time management and problem solving skills required. Must have excellent interpersonal, organizational, and written and verbal communication skills required; highly detail oriented; ability to independently take initiative and exercise good judgment in decision-making.

Proficiency with MS Office Suite (Word, Excel and PowerPoint) with ability to create, edit, and prepare packages and route to appropriate individual(s). Must have expertise in MS Outlook and must understand meeting and calendar functions. Organizational, time management, problem solving skills required. Experience with Adobe and Microsoft Access required.

Ability to compose correspondence and proof assignments to ensure accuracy of documents; excellent interpersonal, organizational, and written and verbal communication skills required; highly detail oriented; ability to exercise good judgment in decision-making. Must be able to see the overall picture of the department/role and anticipate needs/think ahead when completing work. Ability to work efficiently and effectively under deadline pressures and to simultaneously handle multiple assignments and projects with speed and accuracy; professional maturity; high degree of honesty, integrity and confidentiality; ability to work with individuals in a tactful diplomatic manner that enhances the image of the office.

NOTE: The following descriptions are applicable to this section: 1) Continuous – 6-8 hours per shift; 2) Frequent – 2-6 hours per shift; 3) Infrequent – 0-2 hours per shift

Ability to perform job functions while standing. (Frequent)

Ability to perform job functions while sitting. (Continuous)

Ability to perform job functions while walking. (Continuous)

Ability to work indoors. (Continuous)

Ability to work in confined/cramped spaces. (Infrequent)

Ability to perform job functions from kneeling positions. (Infrequent)

Ability to bend at the waist. (Infrequent)

Ability to squat and perform job functions. (Infrequent)

Ability to perform repetitive motions with hands/wrists/elbows and shoulders. (Continuous)

Ability to reach in all directions. (Frequent)

Possess good finger dexterity. (Continuous)

Ability to twist at the waist. (Frequent)

Ability to perform ‘pinching’ operations. (Infrequent)

Ability to fully use both hands/arms. (Continuous)

Ability to fully use both legs. (Continuous)

Ability to reach in all directions. (Continuous)

Ability to lift and carry 15 lbs. unassisted. (Infrequent)

Ability to lift/lower objects 15 lbs. from/to floor from/to 36 inches unassisted. (Infrequent)

Ability to lift from 36 inches to overhead 15 lbs. (Infrequent)

Ability to