"Alerted.org

JOB SUMMARY:

This position is responsible for assessing the readiness of CHS facilities for undergoing regulatory or accrediting surveys including but not limited to The Joint Commission (TJC), American Osteopathic Association (AOA), Centers for Medicare and Medicaid Services (CMS), State Licensing and other federal or state regulatory agencies. The director will work closely with the Clinical Services Department and CHS leadership to address regulatory issues as they are identified, with a focus on sustained compliance.

This position is also responsible for providing regulatory support in applying federal, state or local rules, regulations and/or guidelines that govern healthcare entities.

ESSENTIAL DUTIES AND RESPONSIBILITIES

+ Conduct survey readiness assessments surveys for TJC, HFAP, CMS and State licensing surveys

+ Guide, advise and educate facilities to achieve and maintain compliance with regulatory and accrediting bodies.

+ Conduct follow up activities to support process improvement using the CHS model for improvement in reconciling gaps found during survey assessments both internally and for external agencies.

+ Informs the senior director of quality and survey readiness improvement team of emerging trends and issues identified during readiness assessment surveys

+ Communicates with the Clinical Services Leadership regarding facility-specific regulatory or accreditation concerns

+ Obtains information concerning already identified opportunities prior to performing readiness assessment surveys

+ Generates post survey assessment report with findings and observations to the facility leadership with identified high risk areas to assist in prioritization

+ Collaborates with various corporate subject matter experts to ensure current up-to-date regulatory information is obtained and shared

+ Develops standardized education and resources concerning new and/or revised regulations, standards and guidelines

+ Develops and maintains a database of information related to regulatory and accreditation topics

ADDITIONAL DUTIES:

+ Participates in the development of resource manuals and policies and procedures

+ Assists in situation management events as requested by Clinical Services Leadership

+ Performs special projects, which may include such activities as case management assessments and performing additional focus surveys, at the request of Clinical Services department leadership

EDUCATION & EXPERIENCE

+ Bachelor’s Degree in Healthcare Administration, Nursing, Public Health, or related field required

+ A combination of education and progressive experience in quality or risk management may be considered in lieu of a degree

+ Manager or Director in a clinical setting for a minimum of 5 years required

+ Experience as a Regional Director or Multiple hospital management with a wide range of regulatory experiences to include but not limited to TJC, CMS, OSHA, ASC

+ Registered Nurse with a minimum of 5 years clinical experience, preferred

WORK ENVIRONMENT

+ Requires the ability to handle multiple tasks, meet deadlines and have the flexibility to accommodate unexpected special events/projects

+ Requires excellent verbal and written communication skills and personal computer proficiency

+ **Requires frequent travel - up to 50%**

Equal Employment Opportunity

This organization does not discriminate in any way to deprive any person of employment opportunities or otherwise adversely affect the status of any employee because of race, color, religion, sex, sexual orientation, genetic information, gender identity, national origin, age, disability, citizenship, veteran status, or military or uniformed services, in accordance with all applicable governmental laws and regulations. In addition, the facility complies with all applicable federal, state and local laws governing nondiscrimination in employment. This applies to all terms and conditions of employment including, but not limited to: hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training. If you are an applicant with a mental or physical disability who needs a reasonable accommodation for any part of the application or hiring process, contact the director of Human Resources at the facility to which you are seeking employment; Simply go to http://www.chs.net/serving-communities/locations/ to obtain the main telephone number of the facility and ask for Human Resources.