Job Code Pay Scale Group Pay Scale Type Bargaining Unit Civil Service or Non-Civil Service Last Executive Board Change Executive Board Change History
31970 10 ST A3 C 999-09 11/01/1999
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09/23/1994 31970



This is responsible professional administrative work at the Division level directing a state-wide program for the licensure and/or certification of general hospitals, psychiatric hospitals, ambulatory surgical facilities, and certain specialized services in general hospitals.

The employee in this class plans, directs, and coordinates a statewide regulatory, certification, and licensure program in the aforementioned facilities. As the Chief of the Division of Acute and Ambulatory Care Facilities the employee is administratively responsible for directing field and central office units in order to assure that program activities are carried out and program goals are met within resources available. An important aspect of this work is assuring that program staff provide consultation and continuing education to providers in order to achieve the optimal level of health safety and program capabilities for the clients they serve. The employee is responsible for taking appropriate steps when necessary to resolve difficult licensure/certification issues and to develop plans for resolving on-compliance problems which might precipitate an action to revoke a license, apply a civil penalty or terminate a facility's participation in Federal programs. Work involves a fairly extensive level of contact with other  Divisions in the Bureau of Quality Assurance, other state agencies, legislators, Federal program officials, hospital officials, particularly in relation to those regulations and legislation, to direct the institution of decertification or delicensure proceedings against hospital or other related health care facilities which have failed to comply with state or federal regulations. Supervision is exercised through subordinate health care supervisory staff. Work is assigned by the Director of Quality Assurance in the form of program goals and objectives and the work is carried out with considerable independence. Work is reviewed through conferences, reports and year-end completion of performance objectives.


Directs field and central office units with appropriate delegation of authority in order to assure program activities are carried out and program goals are met with resources available.

Travels to field office locations, survey sites and training locations to ensure compliance with regulations, guidelines and employee performance standards.

Maintains effective and cooperative working relationships with the Department of Public Welfare and the Federal Regional Office in the conduct of problem resolutions for the Medicare Certification Program.

Maintains contact with hospital associations, consumer organizations and officials to promote public understanding and support for program goals.

Analyzes the impact of existing state and Federal regulations as well as pending legislation on the operation of this program. Recommends and secures changes to state regulations in order to maintain a state-of-the-art regulatory base.

Analyzes and interprets program data and implements practices to improve Division performance based on this data.

Coordinates effective and cooperative working relationships with the Division of Safety Inspection and the joint commission on the accreditation of health care organizations.

Evaluates state and Federal training programs in conjunction with the Bureau of training coordinator for effectiveness, and determines unmet training needs of staff, establishes needed programs and recommends attendance.

Receives complaints from hospitals, the legislature, governmental agencies and patients in institutions, investigates and responds, as necessary.

Establishes a mechanism for the uniform interpretation of state rules and regulations and assures staff and providers are informed when information is updated.

Grants or denies exceptions to licensure regulations.

Recommends termination of certification when conditions of participation are not met.

Maintains an effective working relationship with the U.S. Department of Health and Human Services.

Coordinates complaint investigations with the Federal regional office to determine reviewable conditions of participation or services.

Maintains effective working relationships with the Office of Medical Assistance, Department of Public Welfare.

Performs related duties as required.


Knowledge of current principals, practices, and developments in health care as they relate to the regulation of general and psychiatric hospitals as well as other related health facilities.

Knowledge of the principals and practices of public administration.

Knowledge of the principals and practices of supervision.

Knowledge of the functions and resources of Federal, state and municipal organizations which impact on the certification and/or licensure of general and psychiatric hospitals, and other related health facilities.

Ability to integrate the work of a state-wide licensure and certification program for general and psychiatric hospitals with the overall mission of the Bureau of Quality Assurance as well as the Department of Health.

Ability to plan and direct the work of a large professional, technical and clerical staff engaged in a state-wide licensure and/or certification program which encompasses the writing of standards and regulations, and quality assessment.

Ability to understand and apply the legal implications of Federal, state, and local rules and regulations as they apply to general and psychiatric hospitals, and other related health facilities.

Ability to provide advice, consultation, and leadership in relation to issues that arise in the regulation of general and psychiatric hospitals, and other related health facilities.

Ability to analyze and interpret rules, regulations and laws pertaining to the regulation of general and psychiatric hospitals, and other related health facilities.

Ability to establish and maintain effective working relationships with subordinates, associates, state officials and the general public.

Ability to write or orally present technical reports which summarize, explain, or promote the program needs or achievements of this Division.


Five years of professional experience in the field of public health, three years of which must have been administrative, supervisory or consultative in nature.


Any equivalent combination of experience and training which includes three years of professional experience of an administrative, supervisory or consultative nature in the field of public health.