Regulatory Specialist Senior

• Possesses a working knowledge of all The Joint Commission (TJC), Centers for Medicare & Medicaid Services (CMS) Conditions of Participation and State Hospital Licensing Act standards and regulations and stay current with changes to these standards and regulations. Reviews current standards and ensures awareness of new and revised standards. Possesses a working knowledge of organizational policies and procedures and assist with development and revision of Policies and Procedures to ensure compliance with hospital regulations.
• Maintain a state of continual readiness related to The Joint Commission (TJC), Centers for Medicare and Medicaid Services (CMS) Conditions of Participations (CoPs) and State specific regulations. This role supports the hospital (s) using the SSM Regulatory Model, Scope of Service, approach and tools to ensure a stated of constant readiness for survey and compliance laws and regulations.
• Provides education, and consultation and interpretation of regulations and accreditation standards, with an emphasis on hospital, ambulatory, behavioral health, standards and/or regulations.
• Assists in facilitating Facilitates an integrated organizational approach to assessing and meeting regulatory requirements and process improvements. Supports and Facilitates coordination of regulatory surveys for the outpatient and inpatient practice.
• Supports and facilitates coordination of regulatory surveys for the outpatient and inpatient practice. Organizes and leads surveys, also provides ongoing support for survey activity and/or other compliance needs. Utilizes team leading and facilitation skills to support meetings, action plans, development of measures and goals, and data collection. Coordinates all hospital related regulatory inquiries. Facilitate all state, CMS, and TJC on-site visits and remote complaints/investigations. Responsible for developing and monitoring action plans to address compliance issues. Ensures all required regulatory related reports to regulatory agencies and within the hospital and region are completed and submitted accurately and timely.
• Plans and implements systems for assessment and improvement of processes related to hospital operations to ensure regulatory compliance. Coordinates and facilitates hospital wide and clinic tracers. Gathers data from tracers and chart audits to create departmental scorecards related to key compliance issues. Responsible to communicate findings to Administrative Teams. Facilitates the completion of the annual Intracycle Monitoring (ICM), a complete gap analysis of compliance with TJC standards. Works with leaders to develop, implement and monitor action plan for any identified non-compliance.
• Conducts investigations and audits to identify areas of risk, draft a plan for improving compliance practices to address those risks, and monitors to ensure the program is following best practices and standards.
• Serves and Lead in the absence of the Regional Manager.
• Performs other duties as assigned.

• Bachelor's degree

• Three years' experience

• Frequent lifting/carrying and pushing/pulling objects weighing 0-25 lbs.
• Frequent sitting, standing, walking, reaching and repetitive foot/leg and hand/arm movements.
• Frequent use of vision and depth perception for distances near (20 inches or less) and far (20 feet or more) and to identify and distinguish colors.
• Frequent use of hearing and speech to share information through oral communication. Ability to hear alarms, malfunctioning machinery, etc.
• Frequent keyboard use/data entry.
• Occasional bending, stooping, kneeling, squatting, twisting and gripping.
• Occasional lifting/carrying and pushing/pulling objects weighing 25-50 lbs.
• Rare climbing.

• None

SSM Health