Regulatory Consultant

Banner Health•Phoenix, AZ

1d•Hybrid

About The Position

Banner Health is seeking a Regulatory Consultant to join their Regulatory Readiness-Corp team in Phoenix, Arizona. This role focuses on ensuring compliance with regulatory requirements for various affiliated clinics and ambulatory service lines. The consultant will provide on-site support during state surveys, conduct mock surveys, and act as a subject matter expert to leadership and staff. The position involves regular travel across the Phoenix valley and quarterly/biannual travel to Tucson. Banner Health is a large, nonprofit health care system offering stimulating and rewarding careers in a wide array of disciplines.

Requirements

Bachelor’s degree in nursing or other healthcare related field.
Five years of relevant experience in a hospital setting.
Three years of regulatory experience.
Ability to manage programs, projects, and databases.
Demonstrated excellence in interpersonal and written communication skills.
Demonstrated flexibility in responding to the needs of multiple constituencies with a service-oriented philosophy.
Demonstrated ability to lead and facilitate interdisciplinary teams.
Ability to perform complex statistical analysis.
Highly developed problem-solving skills.

Nice To Haves

Prior experience in a surveyor role.
Experience in process improvement.
Experience in regulatory/accreditation programs.
Experience in data management and analysis, including graphic development and presentations.
For clinical assignments, current clinical license/certification.
For life safety and environment of care assignments, Certified Safety Professional (CSP), Certified Health Care Safety Professional (CHCSP) or similar certification.
Additional related education and/or experience.

Responsibilities

Implement regulatory requirements using standardized regulatory processes in one or more facilities/entities.
Prepare facilities/entities for surveys by evaluating standardized infection prevention/control and Environment of Care (EOC)/Life Safety (LSC) regulatory processes.
Review, evaluate, and assist in the development and implementation of facility/entity policies, procedures, and guidelines as they relate to regulatory compliance.
Make recommendations on all facility matters related to compliance with Joint Commission, CMS, national/state/local regulations and/or professional standards.
Conduct observations, tracers, building tours, document reviews, and interviews to ascertain facility compliance with standards, rules, and regulations.
Document findings and provide facilities with reports and recommendations for change.
Complete and update the Joint Commission application.
Provide direction and education to facility functional team leads on completion of the Periodic Performance Review, standardized metrics, and action plans for resolution of identified non-compliance.
Provide tools for ongoing measurement and reporting of compliance with regulatory standards.
Support development and monitor completion of facility plans of correction.
Oversee and assist functional teams and department managers in the development of corrective actions.
Respond to notices of surveyor arrival at facilities by directing survey management activities, clarification of standards, support, and assistance to the senior leadership team.
Initiate and direct post-survey activities to ensure the facility meets regulatory process requirements.
Schedule and participate in unannounced corporate surveys system-wide.
Work with facility leadership and staff to prepare for survey readiness.
Identify and coordinate compliance activities of regulatory content experts such as infection control and EOC/LS specialists.
Provide support and guidance to responders to life safety, environment of care, emergency management, and infection control events.
Evaluate events to ensure standards and regulatory requirements are not compromised.
Report to senior leadership on compliance trends and recommend improvement strategies.
Present data and reports deficiencies identified during internal observations/tracers, and the status of implementation of action plans to senior leadership and at facility regulatory meetings.
Report facility survey readiness status on an ongoing basis.
Update senior leadership on system regulatory compliance trends and certification/accreditation bodies most frequently scored standards.
Serve as a subject matter expert on internal and external regulatory standards.
Provide education to address regulatory changes and gaps in regulatory compliance.
Provide guidance to leaders and staff to ensure they understand regulatory requirements.
Serve on assigned committees, as chair or co-chair as appointed.
Schedule and maintain regulatory meetings, updating the committees on current and future plans and procedures, capabilities, and actions.
Chair the facility function team and be actively involved in the regulatory workgroup.
Maintain regulatory expertise through independent study, attending education workshops, tracking and reviewing regulatory changes, reviewing professional publications, establishing personal networks, and participating in professional societies.
Function autonomously and be responsible for education of leaders and staff system-wide on regulatory issues.