Regulatory Operations Program Manager

Regulatory Operations Program Manager

Bring your passion to Texas Health so we are Better Together

 Work Location: Texas Health Corporate, 612 E. Lamar Blvd., Arlington, TX 76011

Work Hours: Full Time Days (8:00am-5:00pm) for 40 hrs/week 

 Department Highlights:

• Gain a sense of accomplishment by contributing to a teamwork environment.
• Receive excellent mentorship, comprehensive training, and dedicated leadership resources.

What You Will Do: 

I. Regulatory & Accreditation
1. Accesses/interprets/explains applicable regulations and standards; communicates the impact and criticality of applicable regulations and standards, including the added benefit to quality, safety and cost-effectiveness based on evidence-based practices. Use clinical knowledge and expertise to observe patient care, review documentation in the medical record, and evaluate compliance.
2. Conducts regulatory site visits with a focus on clinical aspects of regulatory and accreditation, based on annual and periodic risk assessments, to ensure compliance with TJC and CMS standards and regulatory requirements.
3. Conducts Tracer Inter-Rater Reliability exercises to validate continuous readiness assessments of regulatory/accreditation compliance.
4. Provides informal and formal regulatory/accreditation training to stakeholders as needs are identified. Assists with medical record reviews to identify gaps.
5. Reviews system/hospital policies and system order sets to ensure they adhere to regulatory/accreditation requirements.
6. Participates in healthcare mock survey activities in order to assess ongoing compliance with regulatory/accreditation requirements.
7. Provides support to hospitals/healthcare settings during official regulatory/accreditation surveys and visits
8. Identifies and communicates regulatory updates 50%
II. Professional Engagement
1. Pursues/achieves/maintains required applicable certification and licensure.
2. Pursues professional growth and development of required knowledge and skills.
a. Establishes at least one professional goal per year.
b. Participates in at least five Regulatory-related educational opportunities per year.
3. Participates in a Regulatory-related professional organization.
4. Serves as subject matter expert for TJC/CMS/TAC regulatory operations. 10%
III. Leadership & Integration
1. Utilizes the principles of influence, leadership, and change management to advance program goals and ensure changes are vetted by all stakeholder groups. 
2. Utilizes skills in communication, relationship-building, and facilitation to ensure that all stakeholders feel accountable for continuous regulatory compliance.
3. Contributes to the development of other stakeholders through education and mentorship. 10%
IV. Performance & Process Improvement
1. Identifies opportunities for improvement and continuously looks for ways to improve system processes and reduce harm using the principles of High Reliability.
2. Conducts and develops comprehensive risk assessments, prioritizes potential risks, and recommends evidence-based strategies for risk reduction.
3. Uses PI methodology to assess performance, sets achievable goals, uses data to initiate changes, and develops measures that will ensure sustainability of the improvement.
4. Annual analysis of system tracer program, development of system clinical and behavioral health tracers, implementation, and monitoring of results. 10%
V. Data & Analytics
1. Leverages electronic systems to input, analyze, extract, and manage data to support and drive data integrity, streamline process, innovate practices, and achieve positive outcomes.
2. Creates meaningful electronic reports to enhance clinical regulatory and accreditation initiatives and guide strategy discussions with key stakeholders.
3. Conducts analysis of compliance and provides reports to identified owners and/or key stakeholders.
4. Assists with development of sustainable corrective actions. 10%
VI. Patient Safety
1. Promote a safety culture and infrastructure that aligns with THR?��s strategic objectives and meets regulatory/accreditation standards.
2. Identify active and inactive conditions within the hospital/healthcare setting that could contribute to stakeholder harm.
3. Prioritize high risk findings in order to escalate opportunities for improvement for system leadership awareness and support of risk mitigation strategies. 10%

What You Need:

Education
Bachelor's Degree Healthcare Req
Master's Degree Healthcare/Business Pref

Experience
5 Years Hospital setting/healthcare environment Req
1 Year Regulatory compliance and accreditation or quality improvement Pref

Licenses and Certifications
RN - Registered Nurse Upon Hire Req Or
Other Clinical Licensure Upon Hire Req
CPHQ - Certified Professional in Healthcare Quality 3 Years Req