Regulatory and Accreditation Manager

Ochsner Health • New Orleans, LA

2d • Onsite

About The Position

This job ensures system-wide compliance of environmental safety regulations, including Environment of Care and Life Safety Code standards from The Joint Commission (TJC), United States Pharmacopeia (USP) 800 and hazardous waste disposal regulations, and laser safety. Evaluates and assesses current compliance, implementing necessary changes and identifying potential risks to meet regulatory expectations.
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential duties.
This job description is a summary of the primary duties and responsibilities of the job and position. It is not intended to be a comprehensive or all-inclusive listing of duties and responsibilities. Contents are subject to change at the company’s discretion.

Requirements

• High school diploma or equivalent.
• 5 years of experience in regulatory healthcare, facilities, plant engineering or related.
• Working knowledge of current regulations, including The Joint Commission (TJC), USP <800>, Centers for Medicare & Medicaid Services, National Fire Protection Association, etc.
• Strong interpersonal skills.
• Ability to effectively interact with multiple stakeholders and customers and demonstrate appropriate emotional intelligence in varied situations.
• Proficiency in using computers, software, and web-based applications.
• Strong verbal and written communication skills.
• Organizational and time management skills.

Nice To Haves

• Certified Hospital Safety Professional (CHSP), Certified Hospital Fire Safety Professional (CHFSP), or Certified Hospital Facility Manager (CHFM).

Responsibilities

• Serves as the USP <800> designated person for the company and remains current in and ensures compliance with USP <800> and other applicable laws, regulations, and standards, including but not limited to The Joint Commission (TJC), Centers for Medicare & Medicaid Services (CMS), and Louisiana Department of Health (LDH).
• Completes and prepares mock survey reports, conducts regulatory rounding site visits, and documents review.
• Maintains reports of environmental testing and wipe sampling performed and develops and implements action plans responding to environmental testing and wipe sampling results.
• Ensures environmental control of the storage and compounding areas, participates in regulatory agency inspections of the compounding facility and oversees and uses internally developed systems and/or commercial vendor software to maintain records of facility monitoring.
• Develops and implements appropriate standard operating procedures for risk prevention, updates policies, procedures and other documentation requirements to align with changes in standards, regulations and/or laws and communicates risks that may compromise safety as well as the rationale for prevention policies.
• Participates in TJC, LDH/CMS, and/or other accrediting body licensing surveys, and assists and actively participates in the System Environment of Care Committee.
• Addresses system-level compliance with other regulatory concerns, including laser safety, USP <800> and hazardous waste disposal, reports potentially hazardous situations to the management team, and collaborates with health care professionals to provide training regarding risks to themselves and others resulting from non-compliance.
• Ensures personnel competency and uses internally developed systems and/or commercial vendor software to track personnel competency.
• Performs other related duties as required.
• Remains knowledgeable on current federal, state and local laws, accreditation standards or regulatory agency requirements that apply to the assigned area of responsibility and ensures compliance with all such laws, regulations and standards.

Benefits

• The employer maintains and complies with its Compliance & Privacy Program and Standards of Conduct, including the immediate reporting of any known or suspected unethical or questionable behaviors or conduct; patient/employee safety, patient privacy, and/or other compliance-related concerns.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED