Regulatory/Accreditation Consultant

PeaceHealth•Springfield, OR

About The Position

PeaceHealth is seeking a Regulatory/Accreditation Consultant to coordinate and facilitate accreditation and regulatory work for hospitals in assigned networks. The consultant is accountable for the regulatory and accreditation program within the assigned scope, including identifying gaps in compliance with state hospital licensing and accreditation standards, informing leadership about high-risk issues, and helping local leaders and staff understand the rules relevant to their responsibilities. The role works across disciplines and regulatory departments to coordinate compliance efforts and promote consistent interpretation of applicable requirements throughout PeaceHealth. The consultant leads regulatory survey-readiness planning and supports ongoing readiness, compliance monitoring, internal audits, tracers, and rounding. The role communicates findings to managers, committees, and leadership; helps assign ownership and resolve issues before external reviews; and supports post-survey corrective-action plans, including monitoring and measurement. The consultant maintains reports and summaries, provides regulatory reports to facilities, and creates compliance tools for managers. The position also provides on-site survey support and helps ensure the Survey Command Center is ready to support surveys. It coordinates command-center documentation, processes, and training with facility management and leaders, reviews survey materials at least quarterly, and reviews education at least biannually. The consultant develops and implements regulatory education and standard work, provides local regulatory expertise, serves as a liaison with assigned accreditation and regulatory bodies, and acts as a consultative resource for accreditation and Conditions of Participation questions and state-regulation research. Other duties may be assigned.

Requirements

Associate degree; RN or other clinical background required.
Bachelor’s degree in a health-related field, or equivalent knowledge and skills gained through education, training, and experience.
At least 5 years of experience in a healthcare discipline, regulatory, patient care, quality, or risk.
Excellent verbal and written communication skills.
Excellent organizational skills.
Excellent interpersonal skills.
Ability to exercise independent judgment and close attention to detail.
Ability to maintain confidentiality of highly sensitive information.
Ability to prioritize and manage multiple projects.
Demonstrated skills in team facilitation, project implementation, effective data interpretation, and customer relations.

Nice To Haves

Knowledge of state, federal, and accreditation requirements, including CMS Conditions of Participation for acute-care and critical-access hospitals, accreditation standards, and regulatory areas such as FDA and OSHA.
Registered Nurse credential.

Responsibilities

Lead regulatory survey-readiness program planning in support of PeaceHealth’s mission, vision, and values.
Coordinate oversight of ongoing regulatory readiness with regulatory teams, local leadership, stakeholders, and subject matter experts.
Conduct tracers, internal audits, and rounding to identify vulnerabilities and validate compliance with accreditation and regulatory standards.
Communicate findings and reports to appropriate managers, committees, and leadership.
Address compliance issues proactively, coordinate ownership with other departments and system staff, and support correction before external regulatory reviews.
Coordinate post-survey activities, including creation and continued monitoring of corrective-action plans.
Provide expertise and leadership in developing and implementing action plans, including measurement support.
Maintain reports and summaries of noncompliant issues and survey activity in appropriate databases, and provide scheduled regulatory reports to facilities.
Provide and direct on-site accreditation survey support; help maintain Survey Command Center readiness and serve as a key support during surveys.
Facilitate command-center education, training, and review of documents and processes with facility management and leaders.
Review survey materials at least quarterly and education at least biannually to support coordination and staff knowledge of external survey roles.
Assist with developing and implementing regulatory education and core educational materials for leaders and caregivers.
Provide local regulatory expertise and promote consistent interpretation, standardized processes and practices, and outcomes management.
Participate in creating standard work processes and educate and orient local leaders to them.
Create tools for managers to help maintain compliance in their designated units.
Serve as a liaison between assigned accreditation or regulatory bodies and the hospital.
Provide consultative support by phone or email on accreditation and Conditions of Participation questions, state-regulation research, and compliance approaches.
Participate in system or local teams working on regulatory improvement.
Perform other duties as assigned.