Job Description

Responsibilities*
Essential

Provides leadership and consultation for all aspects of external accreditation and other regulatory reviews, e.g., compliance with The Joint Commission, CMS/Conditions of Participation and other related accreditation and regulatory agencies. Develops, implements, and evaluates PACS specific regulatory readiness activities, using a variety of tools/interventions, e.g., internal, and external surveys, tracers, staff education, facility rounds, engagement of leadership, periodic organizational self-assessment. Promotes, ensures, and monitors both regulatory and corporate compliance.
Develops, implements, and maintains an ongoing Continuous Readiness Plan, in collaboration with the PACS Ongoing Readiness Teams, to achieve compliance with The Joint Commission standards and CMS requirements for deemed status.
Coordinates ongoing readiness activities; provides consultation to departments around compliance initiatives; monitors the progress of improvement projects and corrective action plans.
Provides consultation and support to PACS Directors and is a liaison to Corporate Accreditation and Compliance.
Also serves as a liaison to Michigan Medicine committees purposed with regulatory compliance such as Patient Safety and Emergency Management.
Ensures the completion of all required reports to applicable agencies, e.g., applications, periodic reviews, corrective action plans, performance measures and reportable changes.
Oversees adherence to institutional and external agency requirements and deadlines.
Utilizes principles and tools of lean healthcare and performance improvement in providing project consultation and support for performance improvement efforts.
Maintains current knowledge of accreditation and other regulatory standards.
Leads the PACS Emergency Management Leadership Committee. Plans, organizes, and executes emergency operations drills and exercises. Serves as a member of the UMHS Emergency Management Operations Committee. (EMOC)
Oversees policy and procedure management for Post-Acute Care Services.
Serves in the role of Post-Acute Care liaison, networking with SNF and HHA organizations participating in the PAC Collaboratives and transition of care activities.
Leads PAC Collaborative meetings, working with key MM leadership.
May complete the POM ACO scorecards, sharing outcome data with participating collaborative organizations and promoting discussion and planning for outcome improvement.
Actively participate in the POM ACO PAC meetings.
Manages the SNF 3-Day Waiver process.
Provides day-to-day supervision of designated staff. Creates work schedules for all assigned areas and staff ensuring sufficient staffing is available to meet workload and business needs.
Interviews, selects, hires, on-boards, orientates, and trains new staff.
Provides direction for the planning, implementation, and evaluation of the PACS Education Program, e.g., orientation, competency training, ongoing staff education and all related regulatory requirements.
Participates in strategic planning, leadership meetings and on-call responsibilities for PACS.
Promotes a collaborative and supportive work environment to improve work processes, enhance customer satisfaction and reduce waste. Fosters positive relationships and creates an environment conducive to teamwork to increase employee engagement and job satisfaction. Promotes team problem-solving and decision-making processes.
Demonstrates desired results in achievement of all relevant strategic, budgetary, and operational targets and objectives including, but not limited to, revenue, expense, utilization, and quality indicators.
Incorporates Diversity, Equity, and Inclusion into all activities.
Maintains confidentiality of all patients, regulatory and proprietary information.
Patient and Family Centered Care.
Actively engages the patient and family, as applicable, by exhibiting respect and dignity, sharing information in a timely and unbiased manner, and welcoming and encouraging participation to achieve shared decision making.
Collaborates with other members of the team, including the patient and family, to achieve the ideal patient care experience.
Other Related Duties:

Complies with all University of Michigan and departmental standards and expectations.
Supports the department's commitment to continuous improvement activities and principles through positive and respectful contribution in all problem-solving and change processes at Horne Care Services.
Performs other duties as assigned.
Required Qualifications*
Bachelor's degree in a health care related field, or equivalent combination of education and experience.
Four (4) or more years of administrative/supervisory experience.
Demonstrated knowledge of regulatory and accreditation requirements and standards.
Knowledge of Lean Healthcare principles and quality improvement tools.
Computer proficiency in use of Microsoft Word, Excel, Power Point, e-mail, etc.
Demonstrated verbal, written and presentation skills.
Strong organizational and critical thinking skills.
Demonstrated ability to facilitate teams.
Demonstrated ability to influence outcomes and deliverables.
Able to travel from point A to point B throughout the workday as assigned.