Description: Job Summary:

Conducts regulatory audits and surveys by consulting on the interpretation and interaction of current regulatory policies and requirements in preparation for surveys. Organizes, coordinates, and conducts facilitation of on-site visits and evaluations. Performs site visits in accordance with criteria to ensure survey readiness. Ensures completion of surveys, independently. Conducts routine audits and mock surveys to aid in preparedness, tracking, trending, and facilitation of corrective action plans. Collaborates with others to complete annual reporting. Ensures licensing and accreditation by reviewing requirements for new, expanding, and existing facilities/services in relation to relevant accrediting standards, evaluating relevant risk and impact independently. Consults with departments to ensure certification and conducts complex gap analyses. Serves as the subject matter expert by maintaining and facilitating awareness of internal policies and consulting on the interpretation and interaction of current policies, and how they interact with the current climate, and potential changes to regulations and legislation. Develops complex content and delivers education programs to align policies with regulatory requirements. Conducts data management by entering and analyzing complex practitioner/provider data. Independently reviews, drafts, and provides consultative expertise on implementation of action plans for timely implementation.

Essential Responsibilities:

• Promotes learning in others by communicating information and providing advice to drive projects forward; builds relationships with cross-functional stakeholders. Listens, responds to, seeks, and addresses performance feedback; provides actionable feedback to others, including upward feedback to leadership and mentors junior team members. Practices self-leadership; creates and executes plans to capitalize on strengths and improve opportunity areas; influences team members within assigned team or unit. Adapts to competing demands and new responsibilities; adapts to and learns from change, challenges, and feedback. Models team collaboration within and across teams.


• Conducts or oversees business-specific projects by applying deep expertise in subject area; promotes adherence to all procedures and policies. Partners internally and externally to make effective business decisions; determines and carries out processes and methodologies; solves complex problems; escalates high-priority issues or risks, as appropriate; monitors progress and results. Develops work plans to meet business priorities and deadlines; coordinates and delegates resources to accomplish organizational goals. Recognizes and capitalizes on improvement opportunities; evaluates recommendations made; influences the completion of project tasks by others.


• Serves as the subject matter expert for regulations projects/committees, and internal stakeholders by: providing consultation on the interpretation and interaction of current policies, and how they interact with the current climate, and potential changes to regulations and legislation; serving as a technical advisor on committees and projects to drive development of policies or procedures for regulations and auditing processes; developing complex content and delivering tailored educational programs to align organizational policies and procedures with regulatory requirements; and anticipating and weighing practical/technical considerations in addressing issues and coordinating with the appropriate stakeholders to develop resolutions.


• Develops data management and reporting processes by: entering complex practitioner/provider data and conducts data cleaning as needed; and entering, analyzing, and independently drafting and reviewing action plans/recommendations required data into appropriate databases.


• Ensures licensing and accreditation by: independently reviewing and guiding others to review requirements for new, existing, and expanding facilities/services to aid in achievement of compliance with state, federal, and accrediting standards; consulting with other departments to ensure certification for complex cases; and independently conducting a widely impactful and detailed gap analysis and mentoring others to identify services renewals and planning to ensure services are compliant.


• Identifies and recommends improvements to processes of responding to regulatory audits and survey preparedness efforts by: independently enacting complex reporting, keeping current on regulatory requirements, and guiding others to do the same in preparation for surveys (e.g., NCQA, Joint Commission, AAAHC); serving as liaison between external evaluators, vendors, and senior stakeholders to facilitate on-site visits and evaluations; independently conducting, reviewing, evaluating upon site visit criteria, and performing site visits as appropriate to ensure survey readiness; delivering requested complex audit documentation, information, and reports; assessing the workflow of auditing surveys to identify gaps in completion and reporting, focusing on high vulnerability areas; facilitating educational forums, conducting routine audits, and leading mock surveys within departments to ensure auditing and survey preparedness tracking, trending, and facilitating the development of high impact corrective action plans (CAP) as necessary in collaboration with applicable departments to assure site visit compliance; and leading the collaborations with other departments (e.g., Revenue Cycle), gathering documents and data to support the timely completion of the annual state/federal/regulatory body reporting as required.

Minimum Qualifications:

• Minimum three (3) years of experience in a leadership role with or without direct reports.


• Minimum three (3) years of experience with databases and spreadsheets.


• Bachelors degree in Business Administration, Health Care Administration, Nursing, Public Health, or related field AND minimum seven (7) years of experience in health care operations, quality, risk management, hospital environment, or a directly related field OR minimum ten (10) years of experience in health care operations, quality, risk management, hospital environment, or a directly related field.

Additional Requirements:

• Knowledge, Skills, and Abilities (KSAs): Health Care Policy; Health Care Data Analytics; Consulting; Managing Diverse Relationships; Delegation; Project Management; Risk Assessment; Quality Assurance Process; Credentialing Database Systems; Health Care Quality Standards; Evidence-Based Medicine Principles

Preferred Qualifications:

• Three (3) years of National Committee of Quality Assurance (NCQA) or related survey experience.
• Master's degree in Business Administration, Health Care Administration, Nursing, Public Health, or related field.
• Home Health experience is preferred

Primary Location: California,Pasadena,Walnut Center - Regional Offices
Scheduled Weekly Hours: 40
Shift: Day
Workdays: Mon, Tue, Wed, Thu, Fri
Working Hours Start: 08:00 AM
Working Hours End: 04:30 PM
Job Schedule: Full-time
Job Type: Standard
Worker Location: Flexible
Employee Status: Regular
Employee Group/Union Affiliation: NUE-SCAL-01|NUE|Non Union Employee
Job Level: Individual Contributor
Specialty: Accreditation, Regulatory, & Licensing (AR&L)
Department: Regional Offices - Pasadena - Rgnl Accred Regulation & Lic - 0801
Pay Range: $125900 - $162910 / year The ranges posted above reflect the location in the job posting. The salary range may vary if you reside in a different location or state than the location posted.
Travel: Yes, 25 % of the Time
Flexible: Work location is on-site at a KP location, with the flexibility to work from home. Worker location must align with Kaiser Permanente's Authorized States policy. At Kaiser Permanente, equity, inclusion and diversity are inextricably linked to our mission, and we aim to make it a part of everything we do. We know that having a diverse and inclusive workforce makes Kaiser Permanente a better place to receive health care, a more supportive partner in our communities we serve, and a more fulfilling place to work. Working at Kaiser Permanente means that you agree to and abide by our commitment to equity and our expectation that we all work together to create an inclusive work environment focused on a sense of belonging and wellbeing.

Kaiser Permanente is an equal opportunity employer committed to a diverse and inclusive workforce. Applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy), age, sexual orientation, national origin, marital status, parental status, ancestry, disability, gender identity, veteran status, genetic information, other distinguishing characteristics of diversity and inclusion, or any other protected status. Submit Interest

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