Department:OH1HS_68802_000 Regulatory Compliance
Expected Weekly Hours:40
Position Purpose:At Mount Carmel, we work to continuously inspire one another. Here, all are welcome. It is this culture of humility and compassion that sets Mount Carmel apart. We see the big picture and do the right thing. That means a dedication to the well-being our both our colleagues and the patients they serve.
Being the professional destination for nurses begins with courageous leaders. At Mount Carmel our focus is on leadership development. We designed our dedicated Leadership Academy to provide growth at every level. We encourage participative management. Because true nursing excellence is created when all Nurses are accountable and focused on people-centered care.
Job Description Details:
Our Regulatory Specialist designs and facilitates implementation of effective processes and systems to evaluate compliance and assure continuous accreditation and regulatory compliance. They promote regulatory compliance through integration with daily activities of patient care and in organizational planning for services.
- Stewards human and financial resources in a responsible manner.
- Accountable for the preparation and support of wholly owned facilities, relative to regulatory and licensure compliance.
- Assists in scheduled/unannounced surveys by regulatory agencies.
- Assists in evaluation of regulatory compliance and operations from a process perspective across departments and/or multiple service areas.
- Facilitates and uses change principles to accomplish regulatory compliance and continuous survey readiness.
- Facilitates communication both external and internal to affiliated organizations as necessary to meet regulatory requirements.
- Advises on matters regarding regulatory requirements in the development and implementation of organization plans or activities.
- Serves as a liaison with external agencies (CMS, ODH, JCAHO, etc) as well as Trinity Health System.
- Provides consultation for practical and reasonable interpretations of regulatory requirements.
- Assists in organizational planning for integration of regulatory requirements into daily work activities.
- Manages medical staff dynamics to facilitate effective discussions and participation in regulatory compliance activities.
- Develops and/or assists in conducting educational programs or in-services related to regulatory requirements as needed or requested by the organization.
- Provides, as requested, consulting services to non-MCHS owned health care entities for purposes of building targeted relationships.
- Tailors implementation approaches to different sites and processes.
- Assists managers in identifying solutions to challenging regulatory issues.
- Provides assistance to the Privacy Officer as needed.
- Serves as the Chairperson for the MCHS Administrative Policy Team.
- Serves as the administrative liaison with organ procurement agencies.
- Participates in activities which promote own professional growth and development.
- Serves as liaison between offsite hospital services and Mount Carmel services to support the hospitals’ regulatory requirements.
- Oversees activities necessary to meet initial and ongoing accreditation and licensing requirements. Includes preparation of policies, procedures and plans as needed.
- Acts as resource in policy and procedure development and maintenance.
- Takes active role on System Forms Committee.
- Assists departments in coordination efforts of policies and procedures, forms and performance improvement.
- Tracks new legislation and facilitates discussion and implementation of compliance activities.
- Serves as chairperson of Administrative Policy Team; Maintains on-line administrative policy/procedure site.
- All other duties as assigned.
- Education: Baccalaureate Degree in Health Care field required. Masters in Nursing, Allied Health, or Business preferred.
- Experience: Minimum of five (5) years' recent hospital practice. Clinical and management experience preferred.
- Broad based clinical or management leadership experience with knowledge of complex systems and systems change with demonstrated success in tactical and analytical thinking.
- Knowledge of performance improvement systems and process thinking principles and designs.
- Current knowledge of regulatory and accrediting requirements.
- Proficient computer, written and verbal communications skills; excellent presentation skills with ability to relate effectively to physicians, all levels of the organization and employees in a flexible and adaptive fashion.
- Readily accepts and influences organizational change.
- Understands and applies group process skills.
- Able to incorporate standards interpretation into day-to-day operations.
- Able to travel to multiple area MCHS and affiliated sites
- Able to mobilize action; interactive.
Discovering opportunities, support and excellence – all while making a real difference in patients’ lives – begins at Mount Carmel. Find a new beginning and advance your career with us.
Mount Carmel and all its affiliates are proud to be equal opportunity employers. We do not discriminate on the basis of race, gender, religion, sexual orientation or physical ability.
Trinity Health's Commitment to Diversity and Inclusion
Trinity Health employs more than 120,000 colleagues at dozens of hospitals and hundreds of health centers in 21 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.
Trinity Health's dedication to diversity includes a unified workforce (through training and education, recruitment, retention and development), commitment and accountability, communication, community partnerships, and supplier diversity.