Job Description

  • Job LocationUS-AZ-SCOTTSDALE
    Requisition ID
    01 - Days
    VGPiper Cancer CN-Admin
    John C Lincoln Med Center
    Position Type
    Regular Full-Time
    Physical Work Location and New Employee Orientation Location : Address
    8283 N HAYDEN RD
    Work Hours
  • Overview

    HonorHealth is a non-profit, local healthcare organization known for community service and outstanding medical quality. HonorHealth encompasses five acute care hospitals with approximately 11,500 employees and 4,500 volunteers, over 70 primary and specialty care practices, clinical research, medical education, an inpatient rehabilitation hospital, an Accountable Care Organization, two foundations, and extensive community services.

    HonorHealth is a leader in medical innovation, talent and technology with a genuine commitment to your growth. The health system's vibrant careers take place in an environment filled with opportunity and respect because we see the HONOR in you.


    Bachelor's Degree in healthcare or quality-related field Required

    One (1) year regulatory/accreditation compliance experience within last 5 years Required
    One (1) year quality improvement experience or program / project experience within the last 5 years Required


    Job Summary
    The Regulatory Accreditation Consultant provides operational support and management for federal certification, state licensure, and accreditation compliance programs within the organization. Under direction of Network Director Regulatory/Accreditation, develops, implements, manages and maintains comprehensive programs and projects and provides consultation, education and teaching to leadership, medical staff, and external customers to strengthen network performance in regulatory/accreditation compliance. Initiates/leads necessary improvements to ensure continual compliance with applicable regulatory and accreditation standards. Works closely with Nursing and Patient Safety RNs on performance improvement activities leading to continual performance improvement.
    • Ensures continual network-wide compliance with federal certification and state licensing regulations and accrediting body standards. Serves as the entry-point for regulatory/accreditation issues in maintaining network outpatient center compliance. Leads clinical regulatory and accreditation compliance teams. Coordinates the preparation for regulatory and accreditation surveys to maintain HonorHealth in a state of continual readiness for scheduled and unannounced surveys. Serves as the clinical compliance expert during on-site surveys.
    • Assesses current clinical and non-clinical performance and identifies potential or actual patient safety issues. Coordinates corrective and preventive action when opportunities for improvement are identified. Works in a collaborative manner with facility staff as well as associated Quality staff for improvement. Responds effectively to regulatory and accreditation deficiencies. Assures reporting deadlines are met and data reported are consistent with current requirements to maintain good standing with accrediting/regulatory agencies.
    • Leads clinical quality and continuous improvement teams related to corrective action plans arising out of accreditation, licensing, and complaint surveys. Consults with and supports clinical and non-clinical leadership in executing and sustaining PDSA plans.
    • Facilitates education programs to provide innovative learning experiences for all levels of nursing and other clinical personnel including leadership regarding regulatory and accreditation processes and network performance improvement activities, trends and processes.
    • Serves as a network clinical lead with other Regulatory/Accreditation consultants for ISO internal audit process. Responsible for operationalizing the ISO internal auditing function including: preparing and maintaining an annual schedule of internal audits, ensuring all key processes are audited at least annually, and compiling and trending quarterly audit results to identify opportunities to improve network performance. Submits a regular summary of internal audit results to the network ISO Management Representative.
    • Participates in the formulation and design of network policies, including strategies based on an awareness of quality of care issues relevant to the healthcare system and regulatory and accrediting agency standards.
    • Performs other duties as assigned.

    It is the policy of HonorHealth to provide equal opportunity in employment. Selection and employment of applicants will be made on the basis of their qualifications without regard to race, color, religion, creed, national origin, age, disability, sexual orientation, marital status, veteran status or any other legally protected status.

    Please review the Equal Employment Opportunity poster.

    Please review the Equal Employment Opportunity Poster.HonorHealth wants all interested and qualified candidates to apply for employment opportunities. If you are an applicant with a disability who is unable to use our online tools to search and apply for jobs, please contact us at . Please indicate the specifics of the assistance needed. This option is reserved only for individuals with disabilities that are unable to use the online tools and is not intended for other purposes.

    Application Instructions

    Please click on the link below to apply for this position. A new window will open and direct you to apply at our corporate careers page. We look forward to hearing from you!

    Apply Online