Accreditation and Regulatory Specialist

<p><strong>Position Objective:</strong></p><p>The Accreditation and Regulatory Specialist serves as the expert resource on&nbsp;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.</p><p><strong>Essential Job Duties:</strong></p><p>Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions</p><ol><li>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)</li><li>Uses evidence-based quality improvement methodology to identify areas of vulnerability and assists area leaders in developing corrective action plans.</li><li>Ensures timely analysis and information dissemination of regulatory materials, journals and newsletters for implications on operations.</li><li>Provides timely documentation submission and other information, as required or requested by regulatory and accrediting agencies, to assure compliance.</li><li>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.).</li><li>Coordinates onsite survey due to quality-of-care concerns reported to external agencies</li><li>Provides leadership for health system preparation and readiness for regulatory and accreditation surveys and coordinates mock and on-site regulatory surveys.</li><li>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.</li><li>Participates in regulatory readiness activities across the health system, such as environment of care rounds, and various councils/co