Director of Regulatory Affairs

Duties and Responsibilities

• Manages confidential information within the department and related involved employees, patients, visitors, and/or physicians.
• Responsible for the organization-wide oversight and resolution of regulatory and hospital licensure matters including survey preparation, process changes, new requirements, and compliance with all regulatory standards required for patient safety and quality of care and services.
• Provide organizational support to the Corporate Director of Regulatory Affairs to ensure effective communication and oversight of the organizational responses to unannounced regulatory visits and inspections and timely completion and submission of licenses, applications, certification, and accreditation documentation.
• Aid facility in preparations for surveys (i.e., State, The Joint Commission, Center for Medicare and Medicaid Services, AHCA), conduct quality and patient safety surveys, and ensure continuous readiness for State and Federal surveys.
• Lead or organize tracers/mock surveys with the interdisciplinary team to assess, drive, and maintain continuous survey readiness, communicate findings and concerns, and follow up on action plans across the organization.
• Collaborate with Risk Management in the facilitation of root cause analysis (RCA), failure mode and effects analysis (FMEA) and monitoring of action plan implementation.
• Serve as a liaison with various regulatory agencies and entities for matters on program/hospital/system wide accreditation and licensure and/or certifications.
• Collaborate with the leadership at different levels throughout the organization in establishing and prioritizing goals and actions, process improvements on deficiencies and significant findings relevant to patient safety and quality of care.
• Coordinate the development of data collection tools and review of data.
• Lead, coordinate, investigate, and respond to complaint and/or quality concerns received via Federal and State agencies and related entities.
• Collaborate with Risk Management in relation to incidents that may result in regulatory visits and/or sentinel event reporting.
• Maintain regulatory and other hospital survey readiness and compliance data collection systems with oversight of audit tools and results for continuous compliance and develop statistical and qualitative reports on monthly/quarterly basis to critically oversee the organization's adherence to compliance indicators and target goals.
• Promote the performance improvement, patient satisfaction and employee satisfaction as goals of the organization.
• Serve as a resource to the organization for interpretation of standards of regulatory and accrediting agencies and provide support in the communication and integration towards the mission and vision of the organization to all staff.
• Makes recommendations for improvement and monitors status of resolution regarding identified issues, as appropriate.
• Maintains strict confidentiality of all information discovered in the review process.
• Interpret and evaluate clinical data, identify variations in care/deviation from standards based on specific criteria determined by TJC and CMS.
• Develop TJC preparation timelines and follow-up to successfully meet survey goals.
• Maintain, utilize, and communicate current knowledge of regulatory agency requirements, and standards.

Qualifications

• Generally requires 7 to 10 years of related experience.
• Management experience is required.
• Bachelor's degree in related field is required.
• Master's degree is strongly preferred.
• Valid Florida RN license or other type of healthcare practitioner license is required.