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Regulatory Affairs Director

1 month ago

Miami FL USA, United States Public Health Trust of Dade Co Full time
Job Summary

The Assistant Director of Regulatory Affairs is a key member of the leadership team responsible for ensuring the organization's compliance with regulatory standards and hospital licensure requirements. This role involves overseeing the organization-wide oversight and resolution of regulatory and hospital licensure matters, including process changes, new requirements, and compliance with all regulatory standards required for patient safety and quality of care and services.

Responsibilities
  • Manage confidential information within the department and related involved employees, patients, visitors, and/or physicians.
  • Responsible for the organization-wide oversight and resolution of regulatory and hospital licensure matters, including survey preparation, process changes, new requirements, and compliance with all regulatory standards required for patient safety and quality of care and services.
  • Provide organizational support to the Corporate Director of Regulatory Affairs to ensure effective communication and oversight of the organizational responses to unannounced regulatory visits and inspections and timely completion and submission of licenses, applications, certification, and accreditation documentation.
  • Assist facility in preparations for surveys (i.e., State, The Joint Commission, Center for Medicare and Medicaid Services, AHCA), conducts quality and patient safety surveys, and ensures continuous readiness for State and Federal surveys.
  • Lead or organize tracers/mock surveys with the interdisciplinary team to assess, drive, and maintain continuous survey readiness, communicate findings and concerns, and follow up on action plans across the organization.
  • Participate in organization-wide committees and administrative meetings of various departments and campuses as necessary to address regulatory standards or concerns and relate information to various disciplines as appropriate.
  • Collaborates with Risk Management in the facilitation of root cause analysis (RCA), failure mode and effects analysis (FMEA) and monitoring of action plan implementation.
  • Serve as a liaison with various regulatory agencies and entities for matters on program/hospital/system-wide accreditation and licensure and/or certifications.
  • Collaborate with the leadership at different levels throughout the organization in establishing and prioritizing goals and actions, process improvements on deficiencies and significant findings relevant to patient safety and quality of care.
  • Coordinates the development of data collection tools and review of data.
  • Lead, coordinate, investigate, and respond to complaint and/or quality concerns received via Federal and State agencies and related entities.
  • Collaboration with Risk Management in relation to incidents that may result in regulatory visits and/or sentinel event reporting.
  • Maintain regulatory and other hospital survey readiness and compliance data collection systems with oversight of audit tools and results for continuous compliance and develop statistical and qualitative reports on monthly/quarterly basis to critically oversee the organization's adherence to compliance indicators and target goals.
  • Promotes the performance improvement, patient satisfaction and employee satisfaction as goals of the organization.
  • Serve as a resource to the organization for interpretation of standards of regulatory and accrediting agencies and provide support in the communication and integration towards the mission and vision of the organization to all staff.
  • Performs other related duties as assigned.
  • Makes recommendations for improvement and monitors status of resolution regarding identified issues, as appropriate.
  • Maintains strict confidentiality of all information discovered in the review process.
  • Interprets and evaluates clinical data, identifies variations in care/deviation from standards based on specific criteria determined by TJC and CMS. Develops TJC preparation timelines and follows-up to successfully meet survey goals.
  • Maintains, utilizes and communicates current knowledge of regulatory agency requirements, and standards.
  • Role models behaviors of service excellence and CARE values (Compassion, Accountability, Respect and Expertise).
  • The leader understands and adheres to JHS compliance standards as they appear in the Code of Conduct, Compliance Policies, and all other JHS Policies and Procedures and supports the commitment of JHS in adhering to federal, state and local laws, rules and regulations governing ethical business practices for health care providers by demonstrating knowledge of procedures for protecting and maintaining security, confidentiality and integrity of employee, patient, family and organization information.
  • The leader further understands that JHS is committed to its role in preventing health care fraud and abuse and complying with applicable state and federal laws related to health care fraud and abuse.
  • This commitment is supported and enabled through an anonymous hotline which serves as one of several mechanisms for reporting suspected fraud, waste and/or abuse, as well as other compliance related issues.
  • The leader to report through any of the reporting mechanisms (e.g., anonymous hotline, supervisor, Compliance Officer) any suspected health care fraud, waste and/or abuse as well as other compliance-related issues.
  • Performs all other related job duties as assigned.
Requirements

Generally requires 7 to 10 years of related experience. Management experience is required.

Education

Bachelor's degree in related field is required. Master's degree is strongly preferred.

Credentials

Valid Florida RN license or other type of healthcare practitioner license is required.

Jackson Health System is an equal opportunity employer and makes employment decisions without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran status, disability status, age, or any other status protected by law.