Status: Full Time
Shift: Monday -Friday 8:00 am - 4:30 pm
Exempt: Yes
Summary:
The Regulatory and Accreditation Specialist supports the hospital's compliance with regulatory and accreditation standards through operational execution, monitoring, and coordination of readiness activities. This role functions as a subject matter resource and plays a key role in audits, tracers, policy alignment, and education initiatives.
Other information:
Education, Licensure and/or Work Experience Requirements:
- Experience Required: Minimum 1-3 years of experience in healthcare regulatory, accreditation, quality improvement, administration, or clinical practice.
- Education Required: Bachelor's degree in public health, healthcare administration/management, public policy, nursing, or a related field;
- Excellent communication, analytical, and problem-solving skills. Proficiency in data management systems and Microsoft Office Suite. Ability to lead cross-functional teams and manage multiple priorities.
- Experience Preferred: Strong knowledge of healthcare laws, regulations, TJC, CMS and state health department standards.
- Education Preferred: Master's degree preferred.
- Ability to safely and successfully perform the essential job functions consistent with the ADA, FMLA and other federal, state and local standards, including meeting qualitative and/or quantitative productivity standards.
- Physical Demands: (occasionally, frequently, constantly or SLMHV)
o Strength - Sedentary
o Push - Occasionally
o Pull - Occasionally
o Carry - Occasionally
o Lift - Occasionally
o Sit - Frequently
o Stand - Occasionally
o Walk - Frequently
- Work Environment (occasionally, frequently, constantly)
o Noise Level: (action level is 8 hours/day at 85 decibels. Anything nearing that level classify as loud or very loud)
o Inside/Outside:
o Hazards: Minimal
o Adverse Working Conditions: Long hours of sitting/computer work
Responsibilities:
Essential Duties and Responsibilities:
Regulatory Compliance & Survey Readiness
- Monitor and interpret regulatory and accreditation standards.
- Coordinate and support readiness activities for surveys (TJC, CMS, etc.).
- Conduct mock surveys, tracers, and compliance audits to identify gaps.
- Maintain documentation and evidence required for surveys.
Policy & Procedure Support
- Review policies to ensure alignment with regulatory requirements.
- Partner with departments to update and implement policies.
Education & Training
- Assist in development and delivery of compliance education programs.
- Provide guidance to staff on regulatory standards and expectations.
Performance Improvement & Data Analysis
- Support quality improvement initiatives related to survey findings.
- Collect, analyze, and report data from audits and compliance activities.
Communication & Coordination
- Collaborate with departments to ensure compliance across service lines.
- Support communication with regulatory bodies as directed by leadership.
Non-Essential Duties and Responsibilities:- Support survey logistics and coordination.- Assist with accreditation software/data systems.- Participate in committees and special projects.- Assist with onboarding and regulatory education for new staff.Other duties as assigned