Regulatory/Accreditation Consultant

Job Summary

Supports coordination and facilitation of accreditation and regulatory work for hospitals within assigned networks. Accountable for accreditation regulatory program with assigned scope of responsibility to include, but not limited to identifying gaps in compliance with state hospital licensing and accreditation standards, communicating to leadership on high-risk compliance issues, and supporting the development of local leaders and staff to be aware of rules pertaining to their areas of responsibility relating to regulatory compliance.

Essential Functions

• Leads regulatory survey readiness program planning to support PeaceHealth’s mission, vision and values as related to regulatory compliance.

• Works with regulatory team, local leadership, stakeholders, and subject matter experts to provide oversight to ongoing regulatory readiness within the networks.

• Conducts tracers, internal audits and rounding activities to identify vulnerabilities and to validate compliance with accreditation and regulatory standards.

• Communicates information and report(s) to appropriate managers, committee, and leadership.

• Proactively addresses accreditation and regulatory compliance issues; works with other departments/system staff to assign ownership and works to correct identified issues prior to external regulatory review.

• Serves as the liaison between assigned accreditation/ regulatory bodies and the hospital.

• Supports post survey activities, which include creation and continued monitoring of corrective action plan activity.

• Provides expertise and leadership in the development and implementation of action plans including measurement support.

• Facilitates review and training of survey command center functions, documents and processes with facility management and leaders.

• Reviews survey materials at least quarterly and education at least biannually to ensure strong coordination and staff knowledge of role during external surveys.

• Serves as a consultative resource and is available by phone/email for accreditation/CoP questions, research on state regulations, consult on approaches to compliance, etc.

Qualifications

• Education: Associate Degree Required: RN or other clinical background and Bachelor's Degree Required: in health-related field or equivalent knowledge and skills obtained through a combination of education, training and experiences.

• Experience: Minimum of 5 years Required: Experience in healthcare discipline, regulatory, patient care, quality or risk and Preferred: Knowledge of state, federal and accreditation requirements including but not limited to: CMS Conditions of Participation for acute care and critical access hospitals, Accreditation standards and other regulatory areas such as FDA and OSHA.

• Credentials: Preferred: Registered Nurse.

• Skills: Excellent verbal and written communication skills. (Required) Excellent organizational skills. (Required) Excellent interpersonal skills. (Required) Ability to make independent judgment and pay close attention to details. (Required) Ability to maintain confidentiality of highly sensitive information. (Required) Ability to prioritize and manage multiple projects. (Required) Proven skills in team facilitation, project implementation, effective data interpretation, customer relations. (Required)