REGULATORY SPECIALIST

Position Summary

The Regulatory Specialist reports to the Quality Manager and is responsible for planning, budgeting, monitoring, and evaluating performance related to The Joint Commission, CMS, and other regulatory/licensing agencies. This role involves maintaining current knowledge of all applicable regulations, providing regular educational updates, coordinating the maintenance of the CIHQ contract, and managing onsite survey activities.

Responsibilities

• Provides direction and support to organizational leaders and staff in all areas of regulatory compliance through training and the review, summarization, and dissemination of updates.
• Develops, implements, and maintains a variety of specific plans and processes, addressing related administrative issues that may be linked to program and project responsibilities, and coordinates actions with other operational groups such as Chief Nursing Officers, Information Systems, Infection Preventionists, Facility Management, Facility Senior Leader Teams, etc.
• Remains current with Joint Commission, CMS, and the state of Tennessee regulations in addition to applicable licensing requirements.
• Implements processes and internal audits to ensure the facility remains in a state of continuous readiness.
• Works in collaboration with Regulatory Specialist for Engineering and Human Resources, Infection Prevention Teams, Medical Staff Office, and Environment of Care Teams to ensure coordination or continuous survey readiness through regulatory compliance.
• Conducts regular departmental rounds.
• Works directly with the System Director of Quality and Patient Safety to ensure system safety and reliability.
• Represents the facility onsite during any Joint Commission, CMS, or state survey.
• Assists with other types of regulatory and certification surveys as deemed necessary by Administration.

Qualifications

• Minimum Education: Bachelor’s degree in Nursing OR Associate’s degree in Nursing with two (2) years’ experience in a quality department. Master’s preferred.
• Minimum Experience: Five (5) years’ experience in a hospital setting.
• Able to demonstrate knowledge of Joint Commission standards and Medicare Conditions of Participation. Previous experience in overseeing regulatory compliance in a facility preferred.
• Proficient in the use of Microsoft Office applications.
• Excellent organizational and communication skills required.
• Licensure Requirement: Must have and maintain Tennessee State RN licensure.