Registered Nurse, Regulatory Specialist

Position Summary: Reporting to the Quality Manager, this position is responsible for planning, budgeting, monitoring, and evaluating performance related to The Joint Commission, CMS, and other regulatory/licensing agencies. The Regulatory Specialist is responsible for maintaining current knowledge of all applicable regulations and providing regular educational updates on new and problematic standards to leadership, the facility Regulatory Specialists, and applicable stakeholders. Coordinates the maintenance of the CIHQ contract providing guidance to best utilize educational and mock survey resources. Responsible for timely submission of updates and annual Joint Commission application for triennial survey and any Joint Commission certifications. Coordinates mock survey activities to promote continuous survey readiness and ongoing regulatory compliance. The coordinator is responsible for leading, organizing, and following up on opportunities identified in a monthly regulatory preparation meeting. Actively participates in System activities to support shared learning and regulatory compliance throughout the Health System. The Regulatory Specialist is directly responsible for managing all onsite survey activities including but not limited to: Joint Commission, CIHQ, state surveys, and other regulatory agencies.

Responsibilities: Provides direction and support to organizational leaders and staff in all areas of regulatory compliance through training and the review, summarization, and dissemination of updates. Develops, implements, and maintains a variety of specific plans and processes, addressing related administrative issues that may be linked to program and project responsibilities, and coordinates actions with other operational groups such as Chief Nursing Officers, Information Systems, Infection Preventionists, Facility Management, Facility Senior Leader Teams, etc. Responsible for organizing ongoing review of local policies, updating the local policy site, summarizing policy changes to leadership, and providing input on system policies related to regulatory functions. Collaborates with education to develop and implement educational programs to ensure successful completion of survey visits. Remains current with Joint Commission, CMS, and the state of Tennessee regulations in addition to applicable licensing requirements. Implements processes and internal audits to ensure the facility remains in a state of continuous readiness. Responsible for providing a monthly update, and as needed updates, to leadership of any new or potential regulatory compliance concerns. Responsible for ensuring completion of an FMEA at the facility level at least every 18 months. Directs the activity related to yearly focused standards review and is responsible for overseeing the completion. Responsible for ensuring education and use of Joint Commission Resources products in the facility. Determines schedules and oversees completion of tracer activities and mock surveys on a regular basis. Works in collaboration with Regulatory Specialist for Engineering and Human Resources, Infection Prevention Teams, Medical Staff Office, and Environment of Care Teams to ensure coordination or continuous survey readiness through regulatory compliance. Conducts regular departmental rounds. Works directly with the System Director of Quality and Patient Safety to ensure system safety and reliability. Represents the facility onsite during any Joint Commission, CMS, or state survey. Assists with other types of regulatory and certification surveys as deemed necessary by Administration. Local travel required. Follows policies, procedures, and safety standards. Completes required education assignments annually. Works toward achieving goals and objectives, and participates in quality improvement initiatives as requested. Performs other duties as assigned.

Minimum Education: Bachelor's degree in Nursing OR Associate's degree in Nursing with two (2) years' experience in a quality department. Master's preferred.

Minimum Experience: Five (5) years' experience in a hospital setting. Able to demonstrate knowledge of Joint Commission standards and Medicare Conditions of Participation. Previous experience in overseeing regulatory compliance in a facility preferred. Proficient in the use of Microsoft Office applications. Excellent organizational and communication skills required. Licensure Requirement: Must have and maintain Tennessee State RN licensure. Employee must have a valid Tennessee driver's license and state mandated minimum insurance coverage. Driving record must meet Covenant Health minimum standards at the date of hire and throughout employment tenure.