The Accreditation and Licensing Coordinator is responsible for the preparation, coordination, and maintenance of survey readiness and regulatory compliance. Position requires strong knowledge of healthcare clinical fundamentals and regulatory standards, including, but not limited to, knowledge of Title 22, CMS Conditions of Participation and Center for Improvement in Healthcare Quality. Works independently and directly with Administrative Leadership, Department Directors and the Medical Staff to coordinate and develop any required corrective action plans to address deficiencies.

Works directly with all regulatory agencies to facilitate on site surveys, both planned and unannounced. Must facilitate the collection, compilation, display, and analysis of data to prepare summary reports of regulatory activities.

Provides coaching, support, and direction to the functional teams as well as to medical staff committees as assigned.

PIH Health is a nonprofit, regional healthcare network that serves approximately 3 million residents in the Los Angeles County, Orange County and San Gabriel Valley region. The fully integrated network is comprised of PIH Health Downey Hospital, PIH Health Good Samaritan Hospital, PIH Health Whittier Hospital, 37 outpatient medical office buildings, a multispecialty medical (physician) group, home healthcare services and hospice care, as well as heart, cancer, digestive health, orthopedics, women’s health, urgent care and emergency services. The organization is nationally recognized for excellence in patient care and patient experience, and the College of Healthcare Information Management Executives (CHIME) has identified PIH Health as one of the nation’s top hospital systems for best practices, cutting-edge advancements, quality of care and healthcare technology. For more information, visit PIHHealth.org or follow us on Facebook, Twitter, or Instagram.

Required Skills

• Effective written/oral communication, and presentation skills
• Problem-solving skills
• Strong knowledge of performance improvement tools and techniques
• Proficient computer literacy

Required Experience

• California RN License
• Bachelor’s Degree in healthcare or related field
• CPHQ or HACP (or within 2 years of hire)
• Ability to present to and facilitate medical staff meetings
• Five years acute hospital experience with strong clinical background in acute care, preferably in medical/surgical services.
• Strong knowledge of CIHQ Standards, Title 22, and CMS Conditions of Participation standards and other regulatory agency requirements

Preferred:

• Regulatory Survey Experience preferred
• Training and knowledge in the development and implementation of CMS 2567 corrective action plans
• Two years minimum experience in Quality Management

• Effective written/oral communication, and presentation skills
• Problem-solving skills
• Strong knowledge of performance improvement tools and techniques
• Proficient computer literacy