Accreditation Standards, Administrative Management, Americans with Disabilities Act (ADA), Analysis Skills, Communication Skills, Content Management Systems (CMS), Cross-Functional, Data Analysis, Data Management, FMLA (Family and Medical Leave Act of 1993), Health Department, Healthcare, Healthcare Administration, Hospital, Interpret Regulations, Leadership, Logistics, Maintain Compliance, Microsoft Office, Monitor Regulations, Multitasking, Nursing, Onboarding, People Management, Performance Management, Physical Demands, Policy Implementation, Problem Solving Skills, Public Health, Public Policy, Quality Assurance, Quality Management, Regulations, Regulatory Compliance, Regulatory Requirements, Team Lead/Manager
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
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North Oaks Health Systems