Manager Regulatory and Accreditation Data Operations

Overview

Manages the regulatory and accreditation data collection and submission processes to ensure timely and accurate submission of data to agencies, as well as the dissemination of status and outcomes to appropriate internal stakeholders.  Monitors applicable CMS, Joint Commission and other applicable regulatory/accreditation data requirements and regulations, altering processes as necessary to maintain compliance.

Qualifications

Education:

• Bachelor’s degree in data science, business, healthcare administration, nursing or related discipline or ten years’ equivalent experience with Clinical Data Management required. Bachelor’s within 5 years of employment is strongly preferred.

Licensure/Certification/Registry:

• Completion of the MHS Lean Six Sigma Green Belt curriculum is required within 2 years of job placement.

Experience:

• Minimum five years of experience with clinical data as a system analyst, data abstractor, reporting analysis.  

Other Knowledge/Skills/Abilities:

• Knowledge of the federal (CMS/Medicare), state (IDPH/Medicaid) and Joint Commission quality programs required. Knowledge of other regulatory and or accrediting programs such as Magnet, Trauma Quality Improvement Program (TQIP), American Heart Association’s Get With The Guidelines (Stroke), American Burn Association Registry, or other regulatory and/or accreditation registries preferred.
• Expertise with working with ICD-10 DX, DRG & PCS is required.
• Expertise with healthcare comparative databases (Premier, Advisory Board) is strongly preferred.
• Experience working with CMS’s QualityNet is preferred.
• Ability to communicate with system and senior leadership regarding outcomes and status of registry and accreditation data submissions.
• Ability to manage staff assignments to ensure accurate and timely submission of data for each registry.
• Ability to execute projects from start to finish including the development, measurement and reporting of key performance indicators and commitment to continuous quality improvement required.
• Expertise with coaching and managing multiple clinical and/or technical staff.

Responsibilities

The intent of this job description is to provide a representative summary of the major duties and responsibilities performed by incumbents of this job.  Incumbents may be requested to perform tasks other than those specifically presented in this description.