The Director, Office of Licensure, Accreditation and Regulation directs the Medical Center's operations and activities to comply with licensure, accreditation, and regulation requirements for all heath care sites and services across the continuum including, but not limited to: ambulatory services, hospital services, contract services in collaboration with medical staff, Quality Services, Clinical Operation Teams, Corporate Compliance and Environmental Safety. He/She translates various accrediting, regulatory and licensing agency requirements into action plans to achieve positive survey/audit reviews and renewed licenses; implements systems to effectively monitor compliance to standards and to implement new processes to meet new requirements.
Directs the Medical Center's operations and activities to comply with all licensing and accreditation standards and requirements, ensuring consistency with organizational goals and priorities. Works close with medical staff, executive management, department directors and managers to ensure that principles of confidentiality and responsibility are adhered to. Determines strategy for changing existing process to meet regulatory requirements and translating external demands into program goals.
Develops tools that assist in determining exposure to regulatory and accreditation risks. Identifies opportunities to manage and mitigate those risks. Provides guidance and oversight to client and related business unit audit functions to ensure ongoing regulatory and accreditation compliance, and assists client to establish ongoing monitoring and corrective action plans relating to regulatory and accreditation compliance.
Leads clinical compliance projects, and mentors clinical compliance staff. Accomplishes assigned project objectives by direct work performance, including document review, interviews, research, analysis, completion of worksheets, and development of findings/deficiencies as applicable.
Determines strategy for changing existing processes to meet regulatory requirements and translating external demands into program goals.
Interprets and assists in planning responses to new or changing regulations or standards. Collaborates with external regulators to develop standards that promote high quality patient care and serves.
Serves as liaison to professional organizations and licensing/regulatory agencies. Serves as the point of contact for clients as it relates to clinical compliance, including coordinating and collaborating with regulatory bodies and organizational leaders to ensure compliance with regulatory, accrediting, quality of care, and service requirements.
Develops methods for compiling information and record keeping related to quality improvement and compliance monitoring activities and maintains relevant records. Provides guidance and oversight to client and related business unit audit functions to ensure ongoing regulatory and accreditation compliance, and assists client to establish ongoing monitoring and corrective action plans relating to regulatory and accreditation compliance.
Makes recommendations to client's business unit partners for improvements or remediation to risk management, regulatory, and accreditation compliance programs.
Providing healthcare for more than 100 years, Cedars-Sinai has evolved into one of the most dynamic and highly renowned medical centers in the world. Along with caring for patients, Cedars-Sinai is a hub for biomedical research and a training center for future physicians and other healthcare professionals. This attracts exceptional talent to Cedars-Sinai, including world-renowned physician-scientists who seek a place where they can both conduct research and see patients--the ideal formula for discovery and its translation into cures. Our patients benefit from access to doctors at the top of their fields, and our researchers have an ideal community in which to study the impact of healthcare challenges, and reflect that knowledge in their research. The greater Los Angeles area in which Cedars-Sinai resides possesses unparalleled cultural and ethnic diversity which offers outstanding opportunities for translational and clinical research... and a dynamic environment for medical education.Although community based, Cedars-Sinai is a major teaching hospital affiliated with the David Geffen School of Medicine at the University of California, Los Angeles (UCLA). Cedars-Sinai has highly competitive graduate medical education programs in more than 50 specialty and subspecialty areas, a graduate program in biomedical sciences and translational medicine, a clinical scholars program directed towards junior physicians with aspirations to become clinical scientists, and post graduate training opportunities.There are more than 250 full-time faculty members at Cedars-Sinai. The voluntary medical staff, comprised of more than 2,200 specialty board-certified or board-qualified physicians, represent all of the specialties and subspecialties and collaborate with full-time medical staff in the teaching responsibilities of the graduate medical education programs.