Accreditation and Regulatory Specialist

Title: Accreditation and Regulatory Specialist

Job Code: 001824

FLSA Status: Exempt

Position Objective:

The Accreditation and Regulatory Specialist serves as the expert resource on regulatory/ accreditation and licensure standards and expectations for compliance. Designs and implements a systematic approach to ensure a high level of awareness of regulatory and accrediting agency requirements throughout Luminis Health including ramifications of failures in compliance. This position guides the development of hospital policies and practices as they relate to compliance with regulatory and accreditation guidelines. The Accreditation and Regulatory Specialist assists in the interpretation of these standards and regulations. In the Luminis Health system, there are two acute care hospitals, an inpatient substance abuse facility, a behavioral health inpatient facility and ambulatory care sites.

Essential Job Duties:

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions

1. Provides central expertise and consultative guidance regarding accreditation and licensure standards. Provides consultation to all departments on the interpretation and application of The Joint Commission (TJC) accreditation standards and CMS Conditions of Participation to maintain ongoing readiness and coordinates on-going preparation for regulatory survey(s)
2. Uses evidence-based quality improvement methodology to identify areas of vulnerability and assists area leaders in developing corrective action plans.
3. Ensures timely analysis and information dissemination of regulatory materials, journals and newsletters for implications on operations.
4. Provides timely documentation submission and other information, as required or requested by regulatory and accrediting agencies, to assure compliance.
5. Develops working relationships with external agency representatives and key contacts to assist understanding of compliance requirements throughout the health system. Maintains and organizes all critical documentation support in compliance with requirements to include the development of delivery and follow-up documentation (i.e. reports, plans, appeals, etc.).
6. Coordinates onsite survey due to quality-of-care concerns reported to external agencies
7. Provides leadership for health system preparation and readiness for regulatory and accreditation surveys and coordinates mock and on-site regulatory surveys.
8. Assists area leaders in the development of specific educational material to address areas of vulnerability for compliance with standards or unique requirements for special accreditations.
9. Participates in regulatory readiness activities across the health system, such as environment of care rounds, and various councils/committees. Designs and implements continuous readiness activities, including but not limited to rounds, tracers, and internal mock surveys. Provides real time feedback.
10. Identifies and communicates areas of success; celebrates and encourages promotion of best practices. Works collaboratively to develop, deliver, and maintain compliance training programs, ensuring organizational workforce are knowledgeable of applicable regulations.

Educational/Experience Requirements:

• Bachelors degree in Nursing or healthcare related field with a minimum of three years of experience in the provision of accreditation and regulatory compliance or Quality Management.
• Demonstrated knowledge of federal and state regulations related to health care as well as knowledge of Joint Commission healthcare standards, Maryland Hospital Association, State of Maryland, and other legislative and regulatory initiatives. 
• Demonstrated understanding and implementation of continuous quality improvement methodologies in a health care setting. 
• Demonstrated strong interpersonal skills and relationships with all levels of hospital and medical staff. 
• Demonstrated computer literacy with proficiency working knowledge of Microsoft Office. Demonstrated ability to work independently to solve problems
• Motivated, efficient, self-starter skilled in time management
• Strong organizational skills and attention to detail

Required License/Certifications:

• Current licensure as a registered nurse by the Maryland Board of Nursing preferred.
• CPHQ certification or obtain certification within 2 years of hire date. 
• Lean Six Sigma Green Belt preferred.

Working Conditions, Equipment, Physical Demands:

There is a reasonable expectation that employees in this position will not be exposed to blood-borne pathogens.

Physical Demands – Light Duty

The physical demands and work environment that have been described are representative of those an employee encounters while performing the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions in accordance with the Americans with Disabilities Act.

The above job description is an overview of the functions and requirements for this position.  This document is not intended to be an exhaustive list encompassing every duty and requirement of this position; your supervisor may assign other duties as deemed necessary.