Major Responsibilities:

Provide oversight, direction, and coordination for constant survey readiness and compliance with regulatory agencies; monitors licensing and other document renewal for the hospital.Serve as the hospital expert and consultant for all regulatory standards, maintaining current knowledge for standards/requirements, changes, and updates.Lead the QMS Audit program, ensuring QMS Auditors are trained and competent at the hospital. Maintains the internal and external audit log with respective action plans.Facilitates the hospital’s mock survey, participate in other mock surveys and patient tracers according to regulatory requirements. Ensures adequate mock surveyors representing hospital site.Provide ongoing coordination of data and information necessary for accreditation and regulatory bodies, including participating in data collection and providing education and support of the use of software programs utilized for documenting and communicating compliance and appropriate actions.Develop, disseminate, and implement education for leadership, team members, and medical staff regarding accreditation standards and constant survey readiness.Ensures corrective action plans address identified deficiencies and coordinates timely responses to requests.Prepares and presents reports on key regulatory requirements, including maintaining a dashboard on key performance metrics.Facilitates the coordination of all survey visits, both announced and unannounced.Ensures a consistent process is in place for reviewing and revising hospital policies, procedures, documents, and other documented information.

Licensure, Registration and/or Certification Required:

None Required.

Education Required:

Bachelor’s degree in healthcare related field.

Years of Experience:

Typically requires 5 years in health care which includes 3 years regulatory experience.

Knowledge, Skills & Abilities Required:

Knowledge and experience of applying CMS, state agency, and accreditation organization rules, regulations, and standards.Knowledge of ISO 9001 standards through application and use.Expertise in relationship building with both internal and external customers (i.e, regulatory surveyors).Ability to meet tight deadlines for regulatory responses.Proficient use of Microsoft Office suite.Ability to problem solve, lead multi-disciplinary teams, use conflict management, and team building skills.Detail oriented and able to prioritize and organize data and projects.Excellent interpersonal, written, and verbal communication skills.

Physical Requirements and Working Conditions:

Ability to sit for extended periods of time.Exposed to normal office environment.Operates all equipment necessary to perform the duties of the job.

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.