Regulatory Readiness Manager

About the position

The Regulatory Readiness Manager is responsible for coordinating, planning and organizing the overall regulatory readiness (e.g. CMS, DPH, TJC) of Connecticut Children's. Recommends and implements improvements in key processes, policies and/or procedures as they relate to regulatory compliance. Works as an internal consultant with medical staff, nursing, support services, and other departments to plan, organize, facilitate, implement and measure efforts to improve process efficiencies, assess regulatory compliance and improve overall patient safety and clinical quality. This position reports to the Senior Vice President, Quality.

Responsibilities

• Gauge the readiness and compliance for internal and external surveys by DPH, TJC, CAP, OSHA, and others.
• Responsible for site visit preparation, coordination of site visit logistics and response, as well as the coordination of report-out to management of major regulatory changes and issues and mock or real survey results.
• Coordinate and lead tracer rounds (mock surveys) to assess compliance with regulatory requirements and help prioritize and remediate to improve performance.
• Develop and disseminate mock and real survey issues related to regulatory standards and hospital policy compliance.
• Create and develop strategic educational and training programs relating to compliance issues, safety and quality issues, and continuous regulatory readiness.
• Facilitate the coordination of multidisciplinary efforts in regard to regulatory readiness.
• Collaborate with colleagues to support and coordinate clinical safety and quality activities throughout the institution.
• Provide leadership, guidance and facilitation to clinical and non-clinical departments.
• Ensure compliance with regulatory standards for quality and safety reporting.
• Provide key regulatory safety and quality data highlighting business and operational issues requiring management attention and resources.
• Participate in department task forces and committees to provide operational input.
• Lead, facilitate and coordinate projects to improve clinical and non-clinical areas.
• Develop and manage action plans and measurements of success data to ensure institution-wide oversight of all regulatory compliance needs.
• Work with functional and departmental leaders to develop action plans, corresponding timetables and monitor action plans and results.
• Validate evidence of action plans and measurements of success data related to regulatory compliance issues institution-wide.

Requirements

• Bachelor's degree in health related field required.
• Experience with accreditation survey processes required.
• 5 - 7 years of progressive clinical experience.
• 3 - 5 years' experience in project management.
• Current healthcare licensure in the state of Connecticut, RN preferred.

Nice-to-haves

• Master's preferred.
• Experience with CAP, Workout and LEAN preferred.