Regulatory Consultant

Banner Health•Mesa, AZ

4d•Hybrid

About The Position

The Regulatory Consultant plans, coordinates, implements, and evaluates regulatory programs for facilities and entities to support preparedness and accreditation, certification, and licensure requirements. The role serves as a subject matter expert to leaders, staff, and system teams on regulatory requirements, helping ensure applicable standards are met. Work is confidential and protected from discovery by subpoena under applicable state, Department of Health Services, Joint Commission, and CMS regulations. This position supports multiple east valley acute care facilities and participates in system-wide regulatory activities. It includes on-site support during state surveys, mock surveys, observations and rounds, staff coaching and education, and remote work such as virtual meetings and data review. Travel is minimal. The position works autonomously and provides system-wide education on regulatory issues.

Requirements

Bachelor’s degree in nursing or another healthcare-related field.
Five years of relevant experience in a hospital setting and three years of regulatory experience.
Strong knowledge of regulations and standards in the area of focus.
Ability to manage programs, projects, and databases.
Demonstrated excellence in interpersonal and written communication.
Flexibility in responding to multiple constituencies and a service-oriented philosophy.
Demonstrated ability to lead and facilitate interdisciplinary teams.
Ability to perform complex statistical analysis and highly developed problem-solving skills.

Nice To Haves

Prior experience in a surveyor role.
Experience in process improvement, regulatory/accreditation programs, data management and analysis, including graphic development and presentations.
For clinical assignments, a current clinical license or 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 and standardized processes across one or more facilities or entities.
Prepare facilities for surveys by evaluating infection prevention and control, Environment of Care, and Life Safety regulatory processes.
Review, evaluate, and help develop and implement policies, procedures, and guidelines related to regulatory compliance; recommend actions to meet applicable standards.
Conduct observations, tracers, building tours, document reviews, and interviews; document findings and provide reports and recommendations.
Complete and update the Joint Commission application.
Educate and guide facility functional team leads on Periodic Performance Reviews, standardized metrics, action plans, and measurement and reporting of compliance.
Support development of facility plans of correction, monitor their completion, and assist functional teams and department managers with corrective actions.
Direct survey-management activities when surveyors arrive, clarify standards, support senior leadership, and lead post-survey activities.
Schedule and participate in unannounced corporate surveys; work with facility leaders and staff on survey readiness and coordinate regulatory content experts.
Provide guidance during life safety, environment of care, emergency management, and infection control events, evaluating whether regulatory requirements are maintained.
Report compliance trends, deficiencies, survey readiness, action-plan status, and improvement recommendations to senior leadership and facility regulatory meetings.
Serve as a subject matter expert on internal and external regulatory standards and educate leaders and staff on regulatory changes and compliance gaps.
Serve on assigned committees, chair or co-chair as appointed, maintain regulatory meetings, and participate in facility functional teams and regulatory workgroups.
Maintain regulatory expertise through independent study, workshops, review of regulatory changes and professional publications, networking, and professional societies.