Accreditation and ISO Program Manager

• Area of Interest: Business Professionals
• FTE/Hours per pay period: 1.0
• Department: Quality Improvement- SLRMC
• Shift: Full Time M-F
• Job ID: 187665

Overview

UnityPoint-St Luke's

Full-Time Days

Monday-Friday

The Accreditation and ISO Program Manager provides oversight to ensure a continuous state of readiness with all regulatory and accrediting agencies, including DNV, CMS, and state health departments. This role leads and contributes to efforts to drive high reliability and achieve compliance with accreditation standards and regulatory requirements. The Accreditation and ISO Program Manager collaborates across departments to oversee audits and surveys, ensure timely implementation of corrective actions and performance improvement strategies.

Why UnityPoint Health?

At UnityPoint Health, you matter. We’re proud to be recognized as a Top 150 Place to Work in Healthcare by Becker's Healthcare several years in a row for our commitment to our team members.

Our competitive Total Rewards program offers benefits options that align with your needs and priorities, no matter what life stage you’re in.  Here are just a few:    

• Expect paid time off, parental leave, 401K matching and an employee recognition program.
• Dental and health insurance, paid holidays, short and long-term disability and more. We even offer pet insurance for your four-legged family members.
• Early access to earned wages with Daily Pay, tuition reimbursement to help further your career and adoption assistance to help you grow your family.

With a collective goal to champion a culture of belonging where everyone feels valued and respected, we honor the ways people are unique and embrace what brings us together.  

And, we believe equipping you with support and development opportunities is a vital part of delivering an exceptional employment experience.

Find a fulfilling career and make a difference with UnityPoint Health.

Responsibilities

Survey Coordination & Readiness

Serve as a primary point of contact for accrediting and regulatory bodies (e.g., DNV, IDPH, IDIAL, WDHS, CMS).

• Lead regulatory surveys, compiles action plans from the responsible

parties and submits plans by due date.

• Support internal investigations that may require self reports to

regulatory agencies.

• Tracks and communicates progress in meeting the action plans.
• Monitors changes in regulatory standards and provides education to

staff and leadership regarding standards or interpretive guidelines.

• Acts as a resource to committees/workgroups regarding required

regulations.

• Performs audits as appropriate to assure compliance with standards or

changes in standards.

• Maintains a master list of ISO audits done annually.
• Tracks action plans associated with ISO audits.
• Assures results of all ISO audits are presented/discussed with the

Quality Management Oversight Committee.

• Lead the development and implementation of a robust continuous

survey readiness program.

• Coordinate all accreditation surveys and facilitate mock surveys,

tracers, and documentation review

• Serve as a subject matter expert to hospital leadership, departments,

and committees on regulatory standards.

• Maintains market level accreditation applications and leads self

reporting processes.

• Travel, with no notice, to other UPH hospitals to support surveys and

survey readiness

Operational Improvement

Partners with internal, external, and community stakeholders to assist

with strategy development and improvement.

• Coordinates plans that include a regional vision to the system

strategy.

• Works to continually lead improvement processes and incorporate the

latest evidence-based guidelines and standards into practice, providing

innovative solutions for process improvement and operational

improvement.

• Analyzes data, communicating with key leaders and clinicians to

improve results.

• Assists with root cause analyses process and shares as needed, driving

improvement.

Program and Project Leadership

Leads market level project teams to define, improve, and evaluate

processes. Uses principles of performance improvement to standardize

and hardwire.

• Works closely with quality improvement, patient care services, nursing

operations and many other stakeholders to utilize data to drive change

through implementation of plans.

• Leads market level initiatives and improvements between departments

and differing levels of care to obtain/maintain optimal processes.

• Serves as a point of contact for teams when multiple areas are

assigned to the same project to ensure team actions remain in sync.

• Develops and delivers content, policies, procedures, and education.
• Performs analysis of existing tools to identify further optimization /

opportunities.

• Exhibits collegial communication skills that enhance outcomes and

goal attainment, leads in a manner that unifies and enhances success.

Qualifications

• Education: Bachelor’s degree in healthcare related field or leadership required.
• Experience: Minimum of 5 years’ experience in healthcare setting and previous experience with quality improvement processes and analytical skills required.
• License/Certifications: Certified Healthcare Operations Professional-Basic or Advanced- DNV Healthcare, Inc. within 1 year required.
• Knowledge/Skills/Abilities: Consistently utilizes exceptional written and verbal communication skills. Quickly establishes effective working relationships with multiple stakeholders. Accountable for delivery of outcomes according to plans and timelines. Manages multiple priorities and deadlines to meet goals of the region. Utilizes exceptional planning and organizational skills. Proficient in Microsoft tools, spreadsheets, outlook, and web. Strong quantitative and qualitative data analysis skills to find creative solutions to difficult and complex problems. Strives for improved outcomes/measures, develop positive working relationships with the multidisciplinary network of stakeholders, and maintain a proactive approach to quality improvement. Travel Required.