The Manager of Accreditation and Regulatory Programs is an expert in matters related to regulatory and accreditation process with application to an enterprise wide scope of responsibility. Provides input and oversight on regulations, interpretation and assessment of risk and improvement for inpatient and outpatient areas. Works with a variety of staff and leaders to maintain a continuous level of preparation for all announced and unannounced surveys. This position utilizes high reliability principles to evaluate and address adherence to state licensing laws, CMS Conditions of Participation, Joint Commission standards or other deeming agencies

1. Maintains expert level knowledge to develop an effective, comprehensive enterprise wide regulatory program that identifies and mitigates risk and promotes safety.
   • Manages a systematic and proactive approach to assess and monitor the regulatory compliance of various areas of the organization. Develops and monitors the regulatory program and integrates process improvement activities into operational prioritization. Demonstrates leadership in decision making and collaborating with others to organize/align work for maximum efficacy. Proactively identifies risk based on national trends and internal performance with developed mitigation strategies
2. Ongoing assessments and evaluation of program considering clinical quality data and outcomes, concurrent observation of practices, tracer findings, mock survey findings, actual survey findings and other pertinent trends.
   • Develops the appropriate infrastructure to organize and sustain improvement efforts. Independently facilitates multidisciplinary teams to address areas of risk with effective action plans for improvement Communicates effectively to a variety of audiences to address organizational improvement and aligns resources to the appropriate administrative personnel. Leads all internal efforts to assess, improve and proactively prepare the organization for unannounced surveys with development of effective action plans to improve performance.
3. Effective management of staff and demonstrates fiscally responsible decision making.
   • Provides comprehensive managerial oversight, support and stewardship including hiring, coaching, counseling, work assignments, budgeting, and evaluations to ensure optimal operations within the Regulatory Department.
4. Communicates effectively and efficiently with a variety of audiences.
   • Communicates effectively, facilitate and manage change, and solve interpersonal and structural conflicts so that those they are leading are able to manage difficult transitions and accomplish needed goals
5. Performs miscellaneous job related duties as requested.

Mission

To advance hope, healing and the best healthcare for children and their families

Vision

Phoenix Children's will be the leading pediatric health system in the Southwest, nationally recognized for exceptional care, innovative research and advanced medical education.

We realize this vision by:

• Offering the most comprehensive care across ages, communities and specialties
• Investing in innovative research, including emerging treatments, tools and technologies
• Advancing education and training to shape the next generation of clinical leaders
• Advocating for the health and well-being of children and families

Values

• We place children and families at the center of all we do
• We deliver exceptional care, every day and in every way
• We collaborate with colleagues, partners and communities to amplify our impact
• We set the standards of pediatric healthcare today, and innovate for the future
• We are accountable for making the highest quality care accessible and affordable