Accreditation/Regulatory Affairs Manager

Job Description Summary

The Regulatory Affairs / Accreditation Manager (Charleston-Orangeburg/Nexton campus) reports to the Charleston Director for Regulatory Affairs/Accreditation. This position 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. Additionally, this position is responsible for education of all care team members on regulatory requirements to ensure compliance with federal, state, local and other regulatory agencies as needed.

The Manager ensures regulatory and accreditation standards are met through education, rounding, unit surveillance, and chart reviews. Will attend all staff, accreditation, and corporate meetings as assigned to inform leadership and staff about current and new standards and regulations to ensure hospital compliance is maintained. Ensure all The Joint Commission (TJC) documents are updated monthly, in addition to TJC e-app, for both accreditation and certification programs

Entity

Medical University Hospital Authority (MUHA)

Worker Type

Employee

Worker Sub-Type​

Regular

Cost Center

CC002249 CHS - Regulatory/Accreditation

Pay Rate Type

Salary

Pay Grade

Health-31

Scheduled Weekly Hours

40

Work Shift

Job Description

Minimum Requirements

Education

Bachelor's Degree or Equivalent

Work Experience

7 years progressive work experience and 2 years management experience

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.

Additional Job Description

Physical Requirements:

Ability to perform job functions while standing. (Continuous) Ability to perform job functions while sitting. (Continuous) Ability to perform job functions while walking. (Continuous) Ability to climb stairs. (Infrequent) Ability to work indoors. (Continuous) Ability to work outside in temperature extremes. (Infrequent) Ability to work from elevated areas. (Frequent) Ability to work in confined/cramped spaces. (Frequent) Ability to perform job functions from kneeling positions. (Infrequent) Ability to bend at the waist. (Continuous) Ability to twist at the waist. (Frequent) Ability to squat and perform job functions. (Frequent) Ability to perform "pinching" operations. (Frequent) Ability to perform gross motor activities with fingers and hands. (Continuous) Ability to perform firm grasping with fingers and hands. (Continuous) Ability to perform fine manipulation with fingers and hands. (Continuous) Ability to reach overhead. (Frequent) Ability to perform repetitive motions with hands/wrists/elbows and shoulders. (Continuous) Ability to fully use both legs. (Continuous) Ability to use lower extremities for balance and coordination. (Frequent) Ability to reach in all directions. (Continuous) Ability to lift and carry 50 lbs. unassisted. (Infrequent) Ability to lift/lower objects 50 lbs. from/to floor from/to 36 inches unassisted. (Infrequent) Ability to lift from 36" to overhead 25 lbs. (Infrequent) Ability to exert up to 50 lbs. of force. (Frequent) Examples include: To transfer a 100 lb. patient that cannot assist in the transfer requires 50 lbs. of force. For every 100 additional pounds, assistance will be required from another healthcare worker. 20 lbs. of force is needed to push a 400 lb. patient in a wheelchair on carpet. 25 lbs. of force is required to push a stretcher with a patient with one hand. Ability to maintain 20/40 vision, corrected, in one eye or with both eyes. (Continuous) Ability to see and recognize objects close at hand or at a distance. (Continuous) Ability to match or discriminate between colors. (Continuous) Ability to determine distance/relationship between objects; depth perception. (Continuous) Good peripheral vision capabilities. (Continuous) Ability to maintain hearing acuity, with correction. (Continuous) Ability to perform gross motor functions with frequent fine motor movements. (Continuous) Ability to deal effectively with stressful situations. (Continuous) Ability to work rotating shifts. (Frequent) Ability to work overtime as required. (Frequent) Ability to work in a latex safe environment. (Continuous) Ability to maintain tactile sensory functions. (Continuous) (Selected Positions) *Ability to maintain good olfactory sensory function. (Continuous) *(Selected Positions) *Ability to be qualified physically for respirator use, initially and as required. (Continuous) (Selected Positions)

If you like working with energetic enthusiastic individuals, you will enjoy your career with us!

The Medical University of South Carolina is an Equal Opportunity Employer. MUSC does not discriminate on the basis of race, color, religion or belief, age, sex, national origin, gender identity, sexual orientation, disability, protected veteran status, family or parental status, or any other status protected by state laws and/or federal regulations. All qualified applicants are encouraged to apply and will receive consideration for employment based upon applicable qualifications, merit and business need.

Medical University of South Carolina participates in the federal E-Verify program to confirm the identity and employment authorization of all newly hired employees. For further information about the E-Verify program, please click here: http://www.uscis.gov/e-verify/employees