Regulatory Compliance Program Manager

Common Spirit•Tacoma, WA

31d

About The Position

The Regulatory Compliance Program Manager provides operational support and overall coordination for the strategic implementation of Patient Safety and Accreditation and Licensing programs. Ensures all facets of patient safety are identified, and coordinated into a comprehensive plan. Ensures assigned hospitals and clinics are aligned with Joint Commission and standards established through state and federal regulations. Facilitates on-going regulatory compliance activities through extensive rounding on clinical and non-clinical departments at VMFH. Work includes; policy and procedure implementation; survey preparation; survey management and follow-up; assessment of standards compliance and reporting of vulnerabilities to key stakeholders; conducting training in response to identified or potential deficiencies to management, educators and staff. Assists in review/trending of incident report information and provides quality information for internal quarterly review and ongoing physician performance evaluation. Provides guidance and coaching to management aimed at achieving a state of continuous readiness surrounding licensure, accreditation and certification programs as well as ensuring ongoing compliance with state and federal rules and regulations. Incumbent is accountable for keeping knowledge and skills current in assigned subject area through self-education, community networking and professional organization offerings.

Requirements

Bachelor's degree in healthcare administration, nursing or other healthcare-related field.
Five years of progressively responsible related work experience that would demonstrate attainment of the requisite job knowledge.
Minimum of three years of progressive management responsibility in an acute care setting, one (1) of which is related to managing an organization's or department Quality, Safety, or Regulatory Program.
Minimum of two years of clinical, patient experience or equivalent.
Experience developing, and implementing clinical, service and operation process initiatives, both small and large scale.
Any equivalent combination of education and experience which meets requirements and provides the required knowledge, skills and abilities to perform the essential functions of the position.

Nice To Haves

Active Washington State RN License
Certified Professional in Healthcare Quality (CPHQ)

Responsibilities

Provides operational support and overall coordination for the strategic implementation of Patient Safety and Accreditation and Licensing programs.
Ensures all facets of patient safety are identified, and coordinated into a comprehensive plan.
Ensures assigned hospitals and clinics are aligned with Joint Commission and standards established through state and federal regulations.
Facilitates on-going regulatory compliance activities through extensive rounding on clinical and non-clinical departments at VMFH.
Policy and procedure implementation
Survey preparation
Survey management and follow-up
Assessment of standards compliance and reporting of vulnerabilities to key stakeholders
Conducting training in response to identified or potential deficiencies to management, educators and staff.
Assists in review/trending of incident report information and provides quality information for internal quarterly review and ongoing physician performance evaluation.
Provides guidance and coaching to management aimed at achieving a state of continuous readiness surrounding licensure, accreditation and certification programs as well as ensuring ongoing compliance with state and federal rules and regulations.
Incumbent is accountable for keeping knowledge and skills current in assigned subject area through self-education, community networking and professional organization offerings.