Director of Regulatory and Accreditation

Job Profile Summary

The primary purpose of the Regulatory and Accreditation Program is to promote safe, high quality and effective patient care through maintaining accreditation, certification and licensure compliance

Develops and leads a comprehensive regulatory survey readiness program in support mission, values and values. The Regulatory Director, plans, implements, and directs activities that supports compliance with city, state and federal regulatory requirements and associated accreditation requirements.

Reporting directly to the Chief Quality Officer. Knowledge,

Skills and Abilities

Establishes guidelines to meet The Joint Commission accreditation requirements

Plans, implements and directs programs to support continuous survey readiness activities in collaboration with subject matter experts across the organization

Implements educational programs and current resources to support regulatory compliance and survey readiness as part of day-to-day operations

Directs organizational survey readiness and continuous compliance activities including ongoing monitoring through observations of clinical and clinical support areas.

Partners with Leadership to implement risk reduction and continuous compliance activities.

Leads on-site planned and for-cause surveys and inspections in coordination with Leaders and subject matter experts.

Leads post-survey activities including, but not limited to collaboration with leaders on the development of action plans, authoring corrective action plans and other standards compliance plans, and coordination of follow up survey / inspection plans.

Leads, facilitates, and supports organization and System level programs and projects integral to standardizing safe clinical practices and achieving and maintaining regulatory compliance.

Serves as the organization’s point of contact for accreditation and all regulatory agencies (NYSDOH, CMS, Joint Commission) as well as other external partners.

The Regulatory Director is also responsible for

Policy Management programs to ensure compliance with regulations and legal statute.

Ensures evidence based practice is fundamental in resource document processes.

Develops and maintains a comprehensive project plan linked to standards with on-going monitoring and reporting to senior management

Serves as the subject matter expert related to accreditation and regulatory standards.

Collaborates with senior management and clinical staff in leading and managing all aspects of the accreditation process and standard adherence

Conducts training and coaching to support understanding of accreditation standards and requirements.

Develops and manages audit activities to ensure compliance with accreditation standards and develops and maintains a dashboard to demonstrate ongoing compliance

Qualifications

Bachelor's degree required, Master’s Degree preferred.

Expert knowledge of regulatory environment including NYCDOHMH, NYSDOH, Joint Commission, CMS, National Committee for Quality Assurance (NCQA).

3-7 years of experience with accreditation and regulatory survey process, development and follow-up of corrective plans.

Knowledge of TJC’s E-edition software and JCR AMP Tracer software.

Excellent verbal and written communication skills necessary to communicate with all levels of staff and a patient population composed of diverse cultures and age groups

Demonstrate strong leadership and interpersonal communication skills.

Demonstrate excellent organizational and analytical skills.

Proficiency using Microsoft Office and Google Products

Work independently with minimum supervision.

Ability to work under stress and in emergency situations