Create a culture of continuous regulatory readiness through continual proactive risk assessment and mitigation efforts. Manage, oversee and coordinate all activities related to maintaining an ongoing state of regulatory compliance through proactive risk assessments and mitigation efforts. Manage and coordinate on-site investigations and surveys conducted by various regulatory and accrediting agencies. Manage the policy administration infrastructure to support the formulation, review, approval, and dissemination of ABC Hospital policies and procedures.
- Create a culture of continuous regulatory readiness through continual proactive measures. Educate all levels of staff, including managers, directors and senior leaders to regulatory requirements including regulations and standards in development. (20%)
- Conduct regular assessments through audits (formal and informal), mock tracers and mock surveys. Respond to actual or potential noncompliance identified via these assessments by ensuring that appropriate corrective measures have been taken and that they have successfully eliminated the risk or deficiency; oversee ongoing monitoring to ensure sustained regulatory compliance. (20%)
- Support and participate in the Network continuous survey readiness effort: host mock surveys; participate in other hospitals mock surveys; participate in other hospitals investigations, inspections and surveys as appropriate. (15%)
- Manage all aspects of investigations, inspections and surveys conducted by regulatory and accrediting agencies: prepare for and facilitate visits, ensuring appropriate oversight of the regulators/surveyors; respond to deficiencies by ensuring that appropriate corrective measures have been taken and that they have successfully eliminated the deficiency; oversee ongoing monitoring to ensure sustained regulatory compliance. (20%)
- Serves as the hospital's liaison with regulatory and accrediting agencies, including but not limited to: The Joint Commission, The PA Department of Health, OSHA, and the FDA. In this role, represent the hospital during surveys and hearings before regulatory agencies. (10%)
- Ensure that hospital policies and procedures are consistent with laws, regulations and standards; ensure compliance with hospital policies via education, auditing, communicating results of audits, ensuring corrective actions are taken by management staff and overseeing sustained compliance. (10%)
- Other duties as assigned. (5%)
- Bachelor's degree in healthcare, regulatory or compliance
- 1 - 3 years work experience in the regulatory, accreditation or compliance field
- 1 - 3 years supervisory experience
- 3 - 5 years experience facilitating or coordinating investigations or surveys conducted by regulatory or accrediting agencies
- Master's degree in healthcare, regulatory or compliance
- 3 - 5 years work experience in the regulatory, accreditation or compliance field
- Certified Joint Commission Professional
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