Regulatory and Accreditation Manager

Position Highlights

• Department: Quality
• Hours: 40.00 per week
• Shift: Shift 1

Position Summary

Responsible for the interpretation, operationalization and achievement of ongoing compliance with Joint Commission, DPH and CMS standards, for accreditation and licensure of the hospital. Responsible for achievement of ongoing compliance with Joint Commission stroke and joint replacement certifications.

This is an in office position. Primary hours are Monday - Friday with weekend and evening hours as needed.

Essential Duties & Responsibilities

Under the direction of the Director of Quality, Patient Safety and Regulatory:

• Serve as a leader and subject matter expert for Regulatory Survey processes. Works closely with manager, nursing, medical staff and administrative leaders to ensure that the hospital and its satellite clinics are well-prepared for surveys and in compliance with standards.

• Responsible for and manages high level projects, and administrative regulatory functions. Includes designing approaches, determining resources needed, working with and building teams, facilitating completion of all deliverables

• Continuously monitor and interpret changes in healthcare regulations, accreditation standards (e.g., The Joint Commission, CMS, CT DPH), and other relevant legal requirements

• Conducts internal mock tracers and reviews regulatory audits to monitor compliance with regulations, identifying areas for improvement and ensuring timely corrective actions

• Prepares for inspections, ensuring the hospital is ready and compliant (i.e. Triennial Joint Commission survey, Joint Commission disease specific certifications, DPH licensure and violation/adverse event inspections/follow-up)

• Handles inquiries from regulatory agencies, responds to violations and recommends corrective actions

• Oversees assigned Regulatory Policies, DPH Adverse Event Reporting/Sentinel Event Investigation and corrective actions, Interpreter Service Vendor Liaison to ensure regulatory compliance

• Other job related duties as assigned

Minimum Qualifications

• 2 - 5 years regulatory experience in the acute healthcare setting

• Bachelor’s in healthcare related field

• Proficient in root cause analysis

• In-depth experience, understanding and interpretation of CMS, Joint Commission and Connecticut Department of Public Health standards, regulations, laws and surveys

• Strong analytical skills demonstrating the ability to interpret regulations, identify compliance issues, and develop targeted corrective action plans

• Attention to detail and accuracy: Thoroughness in documentation and record-keeping of compliance activities, including audits, inspections and regulatory communications

• Ability to work independently and as part of a team: The role requires both independent work and collaboration with other departments

• Excellent communication skills: Ability to effectively communicate complex regulatory information to various audiences, including staff, regulatory agencies and leadership

• Demonstrates competence in presentations, including ability to plan content, develop presentation, use audiovisual aids

• Proficient in EPIC and GoogleSuite

Preferred Qualifications

• Master’s Degree in healthcare related field

• 2 years experience in a healthcare management or supervisory position

• 5 years regulatory experience in the acute healthcare setting

Comprehensive Benefits Offered

• Competitive and affordable benefits package
• Shift Differentials
• Continuing Education assistance
• Tuition reimbursement
• Student Loan relief through Fiducius
• Quick commute access from I-84, Route 9 and surrounding areas

About Middlesex Health

The Smarter Choice for your Career!

Come join one of Connecticut’s Top Workplaces, and a Magnet designated organization! At Middlesex Health, we have a unique combination of award-winning talent, world-class technology, and patient-first care that's making health care better. Through our affiliation with the Mayo Clinic Care Network, Middlesex Health has access to the most advanced medical knowledge and research available.