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Responsibilities

The Region Director Regulatory Readiness is responsible for providing direction and support to the hospitals and other entities within a designated region (e.g clinics, ambulatory surgery centers), and that appear on a hospital license in the interpretation and compliance of regulations from the Centers for Medicare and

Medicaid Services (CMS), Accrediting Organizations such as The Joint Commission (TJC), Det Norske Veritas (DNV GL), Center for Improvement in Healthcare Quality (CIHQ), and other regulatory agencies (e.g State Licensing). This position serves to support the markets and facilities within a region in achieving full compliance and certification through the key job responsibilities outlined in the section below. This position interacts at many levels across the national, regional, market, healthcare entities, and through service lines of business.

ESSENTIAL KEY JOB RESPONSIBILITIES

• Develops standard ongoing regulatory readiness strategies within the Region to assist facilities in achieving full regulatory compliance and to sustain a constant state of survey readiness.

• Provides education and guidance in writing plans of corrections that are regulatory compliant

• Standardizes regulatory readiness strategies, provides guidance for regulations and standards compliance, identifies areas for improvement and establishes priorities for facilities within the region

• Establish ongoing assessment and development of regulatory readiness leaders that are new to the profession by collaborating with the National Office Regulatory Readiness in creating educational pathways and ongoing mentorship

• Provide subject matter expertise in compliance with Hospital Accreditation Standards, State and CMS regulations, and other accrediting and regulatory agencies

• Represent the region on strategic initiatives and priorities within the Regulatory Readiness Council

• Collaborate with national, region and facility leaders to implement standardized regulatory readiness plans and strategies within the region

• Provides remote and/or on-site facility support and response for regulatory events as needed, oversight for standard auditing coordination with available systems, develops tracking tools for monitoring compliance and identification of trends, assists facilities with termination track to regain full compliance, and establishes a mock survey program for the region either with internal or external resources.

Qualifications

Required Educaiton and Experience:

• Bachelors of Science Degree required; preferably in a related clinical discipline; Master’s Degree strongly preferred.

• Minimum of five (5) years of progressive management responsibility in an acute care setting with seven (7) years of which is related to risk management, patient safety, quality, compliance and/or other related professional experience.

• Must demonstrate adeptness in supporting the development of programs focused on achieving positive outcomes within regulatory

• Experience in an integrated health system is preferred

• Experience in a matrix management environment involving integration of multiple entities is strongly desired

Required Licensure and Certifications:

Healthcare Accreditation or equivalent certification

Required Minimum Knowledge, Skills, Abilities and Training:

• Exceptional knowledge in regulatory compliance standards and regulations

• Demonstrates exceptional ability to communicate clearly, concisely, and accurately to varying stakeholders without direct oversight

• Possess expertise in project management, performance improvement, regulatory compliance, patient safety, and planning

• Demonstrated knowledge of legislative processes, applicable regulations, and outside regulatory agencies

• Highly adaptive and ability to manage multiple priorities

• Strong leadership skills and fiscal management skills, with the ability to create a goal-oriented climate of teamwork, collaboration and consistent achievement of objectives

• Proficiency in analytical, organizational, and

problem-solving skills, with ability to identify system vulnerabilities and develop and apply innovative solutions

• Skilled to conveying complex information clearly and concisely to all levels of staff, management, and outside personnel, with the ability to motivate, influence, and persuade others

\#LI-CHI

Overview

CommonSpirit Health was formed by the alignment of Catholic Health Initiatives (CHI) and Dignity Health. With more than 700 care sites across the U.S. from clinics and hospitals to home-based care and virtual care services CommonSpirit is accessible to nearly one out of every four U.S. residents. Our world needs compassion like never before. Our communities need caring and our families need protection. With our combined resources CommonSpirit is committed to building healthy communities advocating for those who are poor and vulnerable and innovating how and where healing can happen both inside our hospitals and out in the community.

Pay Range

$68.76 - $99.70 /hour

We are an equal opportunity/affirmative action employer.