Accreditation and Policy Manager

Accreditation and Policy Manager

Revision Date: 08/23/2021
Department: Tribal Council
Employment Status: Full Time
Program: Quality/Compliance/Privacy
FLSA Status: Exempt
Reports To: Assistant Director - Quality Assurance and Data Analytics
Schedule: 40 hours/52 weeks
Supervises: Accreditation and Policy Technician
Preference: TERO Ordinance 2017-01, P.L. 93-638

Job Summary

The Accreditation and Policy Manager is responsible for the monitoring and maintaining the Policy Management Program that will house all of the Kenaitze Indian Tribe's (the Tribes) policies, procedures, standard work, forms, Charters, Ordinances, and other documents. The Accreditation and Policy Manager ensures that all documents in the system are managed by responsible leaders in accordance with Federal, State, and accrediting bodies to maintain certification and licensure. Recommendations for documents will meet or exceed best practice principles, encouraging staff to provide quality and safe care for our patients/clients (un'ina). Consults with legal when needed. The Accreditation and Policy Manager will take a lead role in collaborating with department heads in Behavioral Health (BH) and Primary Care to maintain continual compliance with Commission on Accreditation of Rehab Facilities (CARF) standards. Investigation into other potential accreditations will be reviewed annually, with a summary of recommendations to be presented to the Tribal Council.

Essential Functions

  • Conducts regular monitoring, development and training of the Policy Management System to ensure that all established system mandates are followed
  • Collaborates with department managers providing education and guidance regarding effective development of documents
  • Ensures that all regulatory required documents remain active in the system and reflect changes imposed by the regulatory bodies
  • Participates in and/or co-chairs committee meetings
  • Completes and documents quarterly updates on the Annual Quality Assurance/Performance Improvement (QAPI) work plan
  • Communicates obstacles to Director of Quality, Compliance & Privacy in a timely manner. Prepares documents for external surveys/reviews, compliance plan and quality improvement plans
  • Coordinates and delivers staff education
  • Leads strategic planning sessions with departments as needed
  • Stays current with healthcare regulations and standards
  • Seeks continuing education opportunities with the Institute for Healthcare Improvement (IHI), the National Association for Healthcare Quality (NAHQ) or any other professional organizations as applicable

It is the intent of this job description to highlight the essential functions of the position; however, it is not an all-inclusive list. The incumbent may be called upon and required to follow or perform other duties and tasks requested by his/her supervisor, consistent with the purpose of the position, department and/or the Kenaitze Indian Tribe's objectives.

Working Conditions

Lifting Requirements

  • Sedentary work – Exerting up to 10 pounds of force occasionally, and/or a negligible amount of force frequently or constantly to lift, carry, push, pull or otherwise move objects, including the human body. Sedentary work involves sitting most of the time. Jobs are sedentary if walking and standing are required only occasionally, and all other sedentary criteria are met.

Physical Requirements

  • Stand or Sit (Stationary position)
  • Walk (Move, Traverse)
  • Use hands/fingers to handle or feel (Operate, Activate, Use, Prepare, Inspect, Place, Detect, Position)
  • Climb (stairs/ladders) or balance (Ascend/Descend, Work atop, Traverse)
  • Stoop, kneel, crouch or crawl (Position self (to), Move)
  • Talk/hear (Communicate, Detect, Converse with, Discern, Convey, Express oneself, Exchange information)
  • See (Detect, Determine, Perceive, Identify, Recognize, Judge, Observe, Inspect, Estimate, Assess)
  • Taste/Smell (Detect, Distinguish, Determine)
  • Pushing or Pulling
  • Repetitive Motion

OSHA Categories

  • Category III – Normal routine involves no exposure to blood, body fluid or tissue and as part of their employment, incumbents are not called upon to perform or assist in emergency care or first aid


  • Local
  • In-State
  • Out-of-State



  • Bachelor's Degree in Healthcare or related field, or a combination of education and experience may be substituted for a degree


  • Four (4) years of experience in policy development or policy management in a healthcare setting


  • Managerial experience
  • Knowledge and experience working with cultural diversities


  • Must have a valid Alaska State Driver's License and remain insurable under the Tribe's policy

Special Skills

  • Proven ability to work on several projects simultaneously and under tight schedules
  • Ability to develop and facilitate training modules using Adult Learning theory
  • Strong interpersonal skills
  • Experience with standard business documents (e.g. contract language, grants)
  • Ability to work independently, as well as set and meet deadlines
  • Excellent problem-solving skills
  • Excellent writing skills with the ability to create business/healthcare documents
  • Strong knowledge of medical terminology and procedures to address nursing, medical, and BH provider issues related to policies, procedures, etc.
  • Knowledge of Medicaid and National healthcare compliance regulations and practices
  • Experience with Survey prep for accrediting bodies such as CARF, AAAHC, etc.
  • Conducts business in a service-oriented manner that is attentive, pleasant, respectful and kind when dealing with un'ina, visitors, co-workers and others
  • Ability to work independently as well as collaboratively
  • Proficiency in Microsoft Suite, or obtain within 90 days

Kenai, AK

2 day(s) ago

Tribal Affiliation(s)
Any Affiliation