JOB SUMMARY

This job is responsible for providing operational support and overall coordination for the strategic implementation of licensing and accreditation programs consistent with state and federal rules and regulatory requirements. An incumbent assures all facets of licensing and accreditation are identified and coordinated into a comprehensive plan for Virginia Mason Franciscan Health (VMFH) and that assigned hospitals and clinics are aligned with The Joint Commission (TJC) and standards established through state and federal regulations.

An incumbent facilitates on-going regulatory readiness and compliance activities through extensive rounding on VMFH clinical and non-clinical departments.

Work also includes:

• Policy and procedure implementation;
• Survey preparation; survey management and follow-up;
• Assessment of compliance with VMFH standards and reporting of vulnerabilities to key stakeholders;
• Delivering, in response to identified/potential deficiencies, training to management, educators and staff; and
• Providing guidance and coaching to management aimed at achieving a state of continuous readiness surrounding licensure, accreditation and certification programs.

Education/Work Experience Requirements

Bachelor’s degree in a healthcare related field, graduation from an accredited school of nursing, and four years of progressively responsible experience in a clinical or acute care setting that demonstrates the attainment of the requisite job knowledge, skills and abilities.

Or, any equivalent combination of education and experience which meets licensure requirements and provides the required knowledge, skills and abilities to perform the essential functions of the position.

Licensure/Certification

• Current RN licensure by the Washington State Nursing Commission.