Regulatory Readiness Coordinator

Commonwealth of Massachusetts • Tewksbury, MA

1d • Onsite

About The Position

The Department of Public Health at Tewksbury Hospital is looking for a Regulatory Readiness Coordinator (Registered Nurse V). In this role, you will lead hospital-wide initiatives that support continuous readiness for accreditation and regulatory surveys, including The Joint Commission, the Centers for Medicare & Medicaid Services (CMS), the Massachusetts Department of Public Health (DPH), and other oversight agencies. Working closely with clinical and administrative leaders, you will help strengthen quality improvement efforts, foster a culture of compliance, and promote safe, patient-centered care across the organization. This is a great opportunity for an experienced nursing professional who enjoys driving organizational improvement, collaborating with multidisciplinary teams, and serving as a trusted expert in healthcare quality and regulatory standards. You will have the opportunity to influence hospital-wide practices through education, performance improvement initiatives, readiness planning, and strategic leadership.

Requirements

• Knowledge of the principles and practices of healthcare.
• Knowledge of the terminology and standard abbreviations in healthcare.
• Knowledge of the methods used in the preparation of charts, graphs and tables.
• Knowledge of standard clinical policies, procedures, methods and techniques.
• Knowledge of interviewing techniques.
• Knowledge of problem-solving techniques.
• Ability to understand, explain and apply the laws, rules and regulations governing agency operations.
• Ability to give written and oral instructions in a precise, and understandable manner.
• Ability to write clearly and concisely.
• Ability to gather information through observing and questioning individuals, and by examining records and documents.
• Current and valid registration as a professional nurse under the Massachusetts Board of Registration in Nursing.
• Recent graduates from an approved school of nursing must have applied for the first available registered nurse examination.
• Based on assignment, possession of a current and valid Massachusetts Motor Vehicle Operator's license may be required.

Nice To Haves

• Demonstrated experience leading regulatory readiness, accreditation, or healthcare compliance initiatives.
• Strong knowledge of The Joint Commission, CMS Conditions of Participation, and applicable state and federal healthcare regulations.
• Experience developing and implementing quality improvement and patient safety programs.
• Proven ability to lead multidisciplinary teams and influence organizational change without direct supervisory authority.
• Experience conducting regulatory tracers, mock surveys, and readiness assessments.
• Familiarity with performance improvement methodologies such as LEAN, Six Sigma, Root Cause Analysis (RCA), Failure Mode and Effects Analysis (FMEA), or similar approaches.
• Exceptional written and verbal communication skills, with the ability to effectively educate and engage clinical and non-clinical staff.
• Strong analytical, organizational, and problem-solving skills with exceptional attention to detail.
• Experience developing and delivering education and training related to quality, patient safety, or regulatory compliance.
• Ability to build collaborative relationships across all levels of a healthcare organization while fostering a culture of continuous improvement and accountability.

Responsibilities

• Responsible for the development, coordination, and implementation of the continual readiness plan for Joint Commission Accreditation and CMS Condition of Participation.
• Serves as the organizational expert for regulations surveyed through the Joint Commission accreditation standards, CMS condition of participation for hospitals. Supports and monitors compliance of policies and procedures with standards and regulatory requirements.
• Responsible for the interpretation and communication of the regulatory requirements and standards including the applicable hospital licensure requirements. This may include requirements from non-clinical agencies such as Occupational Safety and Health Administration (OSHA).
• Serves as the organizational contact for the Joint Commission account representative and maintains effective working relationship.
• Provides direction and guidance during the Triennial Joint Commission survey as the survey Command Center Leader.
• Oversees the development of remedial action plans and evidence of standards compliance for internal findings as well as any Joint Commission survey findings. Ensures the findings are reported to appropriate committees.
• Chairs the hospital Regulatory Readiness Committee and ensures committee charter, membership and functional responsibilities are supporting the ongoing readiness activities such as standards self-assessment, periodic performance review, tracer activities and action plans for any areas of non-compliance.
• Provides oversight and reports on the progress for ongoing assessment of the continual readiness plan, identification of needed improvements, and preparation and implementation of plans to achieve needed improvements. Ensures the effective use of regulatory readiness software to monitor progress.
• Develops and/or facilitates the development of tools, procedures and learning tools pertaining to regulatory readiness. Provides education and training for accreditation requirements in collaboration with Education Leader (RNVI).
• Leads or participates in hospital performance improvement including root cause analysis, causal analysis, proactive risk assessments including Failure Mode Effects analysis, regulatory readiness activities, and performance improvement methodologies including LEAN/Six Sigma.

Benefits

• Comprehensive Benefits
• Employee Benefits and Rewards

What This Job Offers

• Job Type: Full-time
• Career Level: Senior