Regulatory Specialist - Corporate Services Center

At Mount Carmel, we work to continuously inspire one another. Here, all are welcome. It is this culture of humility and compassion that sets Mount Carmel apart. We see the big picture and do the right thing. That means a dedication to the well-being of both our colleagues and the patients they serve. Our focus is on leadership development through a dedicated Leadership Academy, providing growth at every level and encouraging participative management for true nursing excellence.

About the role

Our Regulatory Specialist designs and facilitates implementation of effective processes and systems to evaluate compliance and assure continuous accreditation and regulatory compliance. They promote regulatory compliance through integration with daily activities of patient care and in organizational planning for services.

Responsibilities

• Stewards human and financial resources in a responsible manner.
• Accountable for the preparation and support of wholly owned facilities, relative to regulatory and licensure compliance.
• Assists in scheduled/unannounced surveys by regulatory agencies.
• Assists in evaluation of regulatory compliance and operations from a process perspective across departments and/or multiple service areas.
• Facilitates and uses change principles to accomplish regulatory compliance and continuous survey readiness.
• Facilitates communication both external and internal to affiliated organizations as necessary to meet regulatory requirements.
• Advises on matters regarding regulatory requirements in the development and implementation of organization plans or activities.
• Serves as a liaison with external agencies (CMS, ODH, JCAHO, etc) as well as Trinity Health System.
• Provides consultation for practical and reasonable interpretations of regulatory requirements.
• Assists in organizational planning for integration of regulatory requirements into daily work activities.
• Manages medical staff dynamics to facilitate effective discussions and participation in regulatory compliance activities.
• Develops and/or assists in conducting educational programs or in-services related to regulatory requirements as needed or requested by the organization.
• Provides, as requested, consulting services to non-MCHS owned health care entities for purposes of building targeted relationships.
• Tailors implementation approaches to different sites and processes.
• Assists managers in identifying solutions to challenging regulatory issues.
• Provides assistance to the Privacy Officer as needed.
• Serves as the Chairperson for the MCHS Administrative Policy Team.
• Serves as the administrative liaison with organ procurement agencies.
• Participates in activities which promote own professional growth and development.
• Serves as liaison between offsite hospital services and Mount Carmel services to support the hospitals’ regulatory requirements.
• Oversees activities necessary to meet initial and ongoing accreditation and licensing requirements, including preparation of policies, procedures, and plans as needed.
• Acts as resource in policy and procedure development and maintenance.
• Takes active role on System Forms Committee.
• Assists departments in coordination efforts of policies and procedures, forms, and performance improvement.
• Tracks new legislation and facilitates discussion and implementation of compliance activities.
• Serves as chairperson of Administrative Policy Team; maintains online administrative policy/procedure site.
• All other duties as assigned.

Requirements

• Baccalaureate Degree in Health Care field required. Masters in Nursing, Allied Health, or Business preferred.
• Minimum of five (5) years' recent hospital practice. Clinical and management experience preferred.
• Broad-based clinical or management leadership experience with knowledge of complex systems and systems change with demonstrated success in tactical and analytical thinking.
• Knowledge of performance improvement systems and process thinking principles and designs.
• Current knowledge of regulatory and accrediting requirements.
• Proficient computer, written, and verbal communications skills; excellent presentation skills with ability to relate effectively to physicians, all levels of the organization, and employees in a flexible and adaptive fashion.
• Readily accepts and influences organizational change.
• Understands and applies group process skills.
• Able to incorporate standards interpretation into day-to-day operations.
• Able to travel to multiple area MCHS and affiliated sites.
• Able to mobilize action; interactive.