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Job Title: RN, Clinical Regulatory ComplianceDepartment: Clinical Regulatory Compliance Location: Newark Wayne Hospital (also floating to Clifton) Hours Per Week: 40 Schedule: M-F 8am-4:30pm SUMMARY: Provides and supports regulatory, accreditation and certification activities to achieve and sustain ongoing compliance. Takes action to assure timely and complete preparation, support and follow-up to surveys, reviews and investigations. Represents the organization in interfaces with regulatory and accreditation agencies. Remains current with state and federal regulations and communicates that information within the organization. Works closely with leaders to develop and implement plans to meet new or revised regulations or standards. Collaborates with Performance Improvement and Patient Safety personnel, as well as affiliate and department leaders to promote and maintain compliance .

RESPONSIBILITIES:

+ Develops and maintains up-to-date knowledge of state and federal healthcare regulations, including DNV and TJC accreditation standards, and participates in the evaluation of organizational compliance.

+ Collaborates on the development, implementation, and monitoring of regulatory and accreditation plans, programs, and reports across departments and service lines.

+ Identifies risks and facilitates appropriate risk reduction strategies, utilizing quality improvement tools to address deficiencies and support patient safety initiatives.

+ Serves as a regulatory resource, providing interpretation of standards, coordinating educational efforts, and disseminating updates to staff, leadership, and committees.

+ Represents the organization in interactions with external regulatory agencies such as DNV, TJC, DOH, OMH, IPRO, and OHSM, and ensures timely submission of required plans of action.

+ Works closely with department leaders to monitor compliance with regulatory requirements, address persistent noncompliance, and promote continuous readiness and survey preparedness.

+ Supports cross-functional collaboration to enhance clinical excellence, regulatory compliance, and quality outcomes through data analysis, reporting, and participation in system-wide initiatives.

REQUIRED QUALIFICATIONS:

+ Bachelor’s degree in nursing from an accredited educational organization required OR must obtain within three years upon date of hire.

+ Registered Nurse licensure in New York State

PREFERRED QUALIFICATIONS:

+ Experience working with regulatory and accreditation systems (eg. DOH, NYPORTS, TJC, IPRO, OMH).

+ Experience in large group presentation and facilitation.

+ Experience with data analysis and QI/PI preferred.

+ Working knowledge of computer software including Microsoft Word, Excel, Power Point and Outlook.

+ Strong communication, organizational, and interpersonal skills

+ Master’s degree in nursing preferred.

EDUCATION:

LICENSES / CERTIFICATIONS:

PHYSICAL REQUIREMENTS:

S - Sedentary Work - Exerting up to 10 pounds of force occasionally Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.

For disease specific care programs refer to the program specific requirements of the department for further specifications on experience and educational expectations, including continuing education requirements.

Any physical requirements reported by a prospective employee and/or employee’s physician or delegate will be considered for accommodations.

PAY RANGE:

$78,000.00 - $105,000.00

CITY:

Newark

POSTAL CODE:

14513

The listed base pay range is a good faith representation of current potential base pay for a successful full time applicant. It may be modified in the future and eligible for additional pay components. Pay is determined by factors including experience, relevant qualifications, specialty, internal equity, location, and contracts.

Rochester Regional Health is an Equal Opportunity/Affirmative Action Employer. Minority/Female/Disability/Veterans by a prospective employee and/or employee’s Physician or delegate will be considered for accommodations.