Regulatory Coordinator

Department :

12830 Advocate Aurora Health Corporate - Quality WI Region

Status : Full time

Full time

Benefits Eligible : Hou rs Per Week :

Hou rs Per Week :

Schedule Details / Additional Information :

M - F 7 : 30-4 : 00

Major Responsibilities :

• Provide oversight, direction, and coordination for constant survey readiness and compliance with regulatory agencies; monitors licensing and other document renewal for the hospital.
• Serve as the hospital expert and consultant for all regulatory standards, maintaining current knowledge for standards / requirements, changes, and updates.
• Lead the QMS Audit program, ensuring QMS Auditors are trained and competent at the hospital. Maintains the internal and external audit log with respective action plans.
• Facilitates the hospital's mock survey, participate in other mock surveys and patient tracers according to regulatory requirements.

Ensures adequate mock surveyors representing hospital site.

• Provide ongoing coordination of data and information necessary for accreditation and regulatory bodies, including participating in data collection and providing education and support of the use of software programs utilized for documenting and communicating compliance and appropriate actions.
• Develop, disseminate, and implement education for leadership, team members, and medical staff regarding accreditation standards and constant survey readiness.
• Ensures corrective action plans address identified deficiencies and coordinates timely responses to requests.
• Prepares and presents reports on key regulatory requirements, including maintaining a dashboard on key performance metrics.
• Facilitates the coordination of all survey visits, both announced and unannounced.
• Ensures a consistent process is in place for reviewing and revising hospital policies, procedures, documents, and other documented information.

Licensure, Registration and / or Certification Required :

None Required.

Education Required :

Bachelor's degree in healthcare related field.

Years of Experience :

Typically requires 5 years in health care which includes 3 years regulatory experience.

Knowledge, Skills & Abilities Required :

• Knowledge and experience of applying CMS, state agency, and accreditation organization rules, regulations, and standards.
• Knowledge of ISO 9001 standards through application and use.
• Expertise in relationship building with both internal and external customers (i.e, regulatory surveyors).
• Ability to meet tight deadlines for regulatory responses.
• Proficient use of Microsoft Office suite.
• Ability to problem solve, lead multi-disciplinary teams, use conflict management, and team building skills.
• Detail oriented and able to prioritize and organize data and projects.
• Excellent interpersonal, written, and verbal communication skills.

Physical Requirements and Working Conditions :

• Ability to sit for extended periods of time.
• Exposed to normal office environment.
• Operates all equipment necessary to perform the duties of the job.

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent.

Incumbent may be required to perform other related duties.

About Advocate Health

Advocate Health is the third-largest nonprofit, integrated health system in the United States, created from the combination of Advocate Aurora Health and Atrium Health.

Providing care under the names Advocate Health Care in Illinois; Atrium Health in the Carolinas, Georgia and Alabama; and Aurora Health Care in Wisconsin, Advocate Health is a national leader in clinical innovation, health outcomes, consumer experience and value-based care.

Headquartered in Charlotte, North Carolina, Advocate Health services nearly 6 million patients and is engaged in hundreds of clinical trials and research studies, with Wake Forest University School of Medicine serving as the academic core of the enterprise.

It is nationally recognized for its expertise in cardiology, neurosciences, oncology, pediatrics and rehabilitation, as well as organ transplants, burn treatments and specialized musculoskeletal programs.

Advocate Health employs 155,000 teammates across 69 hospitals and over 1,000 care locations, and offers one of the nation's largest graduate medical education programs with over 2,000 residents and fellows across more than 200 programs.

Committed to providing equitable care for all, Advocate Health provides more than $6 billion in annual community benefits.