RN Regulatory Program Coordinator

• 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 the organization
• Guide the development of policy and guidelines as they relate to the hospital and compliance with regulatory and accreditation guidelines
• Assist in the interpretation of these policies
• Provides central expertise regarding accreditation and licensure standards
• Identify, plan for, communicate, monitor, and evaluate actions to comply with existing and new regulations, standards and accreditation requirements throughout the organization
• Provides leadership for organizational preparation and readiness for regulatory and accreditation surveys
• Implements a periodic organizational needs assessment for regulatory compliance including Intra-cycle Monitoring (ICM), using the Focused Standards Assessment (FSA) Tool required by The Joint Commission
• Identify areas of vulnerability and assist area leaders in developing corrective action plans
• Identify and communicate areas of success to celebrate and encourage promotion of best practices
• Review, assess, and work to revise relevant medical center policies and procedures and/or recommend and assist with the development of new policies and procedures to ensure compliance with regulatory, accreditation, and professional standards
• Serves as an additional liaison, with the Quality Director, to regulatory agencies and accreditation bodies
• Provides documentation and other information as required or requested on time to assure compliance for regulating and accreditation agencies
• Maintain and organize all critical documentation support in compliance with requirements
• Oversee the development of delivery and follow-up documentation (i.e. reports, plans, appeals, measures, etc.)
• Manage all agency site visits to include scheduling, logistics and communication within the organization
• Provides consultation to all departments on the interpretation and application of TJC accreditation standards and Centers for Medicare and Medicaid Services (CMS) Conditions of Participation to maintain ongoing readiness
• Development of mandatory educational material to meet periodic requirements
• Assist area leaders in the development of specific educational material to address areas of vulnerability for compliance with standards or unique requirements for special accreditations
• Assist the medical center in the review of all educational materials for regulatory or accreditation compliance to assure they reflect medical center practice and congruency with each other
• Adheres to and supports team members in exhibiting TMCH values of integrity, community, compassion, and dedication
• Adheres to TMCH organizational and department-specific safety and confidentiality policies and standards
• Performs related duties as assigned

• Bachelor’s degree in nursing from an accredited institution
• Five (5) years nursing experience in a hospital setting
• Current RN licensure permitting work in the state of Arizona
• Knowledge of regulatory requirements (TJC and CMS)
• Knowledge of the accreditation process
• Knowledge of survey preparation and required follow-up activities
• Skill in written and oral communications
• Skill in conducting mock regulatory surveys using the tracer methodology
• Ability to interpret, prepare, and present reports to management in both written and oral formats
• Ability to make presentations, design and provide training/education to staff and management

Master’s Degree