Job Summary

The Director of Regulatory Affairs is responsible for planning, organizing, implementing and evaluating regulatory compliance initiatives to support patient safety and quality and ensure continuous compliance with Federal, State and local regulatory requirements. This position concentrates on oversight of accreditation and certification processes, including but not limited to, The Joint Commission (TJC), Centers for Medicare and Medicaid Services (CMS), and State/Local Department of Health (DOH) standards, regulations and law, in consultation with JHHS Legal Counsel, as necessary.

This position involves interpreting and operationalizing regulatory requirements, including but not limited to:

• Participating in regulatory-related communication/notification, staff/leadership education, and policy/documentation development or revision as needed

• Coordinating virtual and onsite surveys by external regulatory/accreditation agencies

• Coordinating onsite mock surveys by external consultants or JHHS Office of Accreditation & Certification (OAC)

• Developing and implementing corrective actions and monitoring plans for sustaining improvements over time

• Collaborating on special projects, as requested

• Serving as a resource/consultant to internal and external customers

• Participating in organization and/or health system committees

Qualifications

• Requires a Master’s Degree (healthcare-related preferred). Graduation from an accredited school of nursing, public health or related clinical discipline preferred.
• A minimum of 8 – 10 years of healthcare-related experience required with current knowledge of accreditation/certification processes and performance improvement tools and techniques
• At least 2 years of direct management experience
• Experience in regulatory compliance, performance/quality improvement, patient safety, risk management or project management preferred.
• Licensed or certified in a healthcare related field
• Certified Professional in Healthcare Quality (CPHQ) preferred