The Program Manager, Regulatory& Accreditation Affairs is responsible for leading the Nemours Children’s Health, Florida Regulatory and Accreditation program, and managing the respective team(s). The Program Manager's primary goal is to ensure that the Nemours Children’s Health, Florida (NCH-FL) remains compliant with all Federal, State and local regulatory requirements, and adheres to all identified accreditation and certification program standards. The Program Manager is expected to collaborate with the Director, Patient Care Services leaders, and others to craft a vision for a best-in-class program that ensures continuous survey readiness, proactive identification and response to emerging regulatory and enforcement trends, and the sustainability of process and culture around regulatory compliance. The Program Manager will be expected to operationalize that vision in partnership with other key stakeholders including nursing, medical and operational leadership. The Program Manager is expected to serve as a subject matter expert and resource, for the team(s) and committees, for the Q&S Department and for the organization as whole. The Program Manager will demonstrate exceptional critical thinking skills, develop a systematic approach to continuous compliance/readiness, lead and grow teams, and develop individual team members.

Position Responsibilities

• Additional miscellaneous duties and responsibilities, as may be assigned from time to time by employee’s supervisor.
• Clinical Activities - Leads compliance with all applicable federal and state regulations. Reviews accreditation compliance across the continuum of children’s care, which includes supporting the planning and implementation of standard clinical practices, protocols and clinical guidelines; documentation, monitoring care and outcomes of hospital patients. Serves as an expert resource in accreditation/regulatory-compliance for clinical practice. 
• Performance Improvement – Participates in clinical processes and outcomes and system reviews related to accreditation compliance. Advises and facilitates policy drafts and revisions for NCH-FL. Supports the implementation of clinical practice guidelines; develops mechanisms for quality filters, audits, and case reviews; identify trends and helps outline remedial actions for accreditation or regulatory compliance while maintaining confidentiality. 
• Administration - Manages the collection and reporting of data (operational, personnel, and financial) to meet with the specific requirements of accreditation standards. Facilitates the procurement of additional licensures, accreditations and certifications across the health system in Florida. Leads the review, response and correction of deficiencies identified by external accreditation and regulatory agencies. Serves as a liaison, and represents the program on various hospital and community committees to enhance and foster understanding and influence the development of regulatory or accreditation standards. 
• Data Collection - Uses proactive data analytics to identify potential regulatory and accreditation risks and collaborates with unit leadership to draft and implement effective and timely corrective action plans. Works in collaboration with leadership, clinical staff, and all members of the Quality and Safety team. Advises and facilitates policy drafts and revisions for NCH FL. 
• Consulting and Liaison – Collaborates to pursue standard compliance throughout the complex network of disciplines that work in concert to provide high-quality children’s care. Rounds in clinical areas to actively assess regulatory readiness. Serves as an internal resource for staff in all departments, interacts routinely with clinical associates in patient care settings, and acts as an extended liaison for other system entities. 
• Research – Is involved, as appropriate, in research studies, analysis, and distribution of findings. 
• Community and National Engagement in Children’s Health Care Systems - Participates in the development of accreditation and regulatory standards, as appropriate, for children’s health care within professional collaborations at the community, and state levels.
• Supervision of staff – is directly involved with management of all responsibilities related to oversight of staff members, as applicable.

Position Requirements

• Bachelors Degree required; knowledge of accreditation standards, survey readiness processes, and regulations application to hospitals, as well as primary/specialty care clinics and other healthcare settings
• Certified Professional in Healthcare Quality preferred or obtained within 2 years
• Minimum of three years experience required; experience in guiding a hospital/health system to achieving and maintain accreditation and ongoing compliance with appropriate local, state, and federal regulations.