Career Center

The Regulatory & Accreditation Consultant is responsible for monitoring, trending, and improving the enterprise wide continuous survey and accreditation readiness plan. Working in collaboration with the leadership of the Center, the consultant will assist the various areas in improving their readiness and sustaining a state of continuous readiness for regulatory and accreditation surveys for all federal, state, local and accrediting bodies, both mandatory and voluntary certifications. This position will serve as the regulatory and accreditation subject matter expert in all areas of the Center. The consultant works with areas in need of assistance in meeting guidelines utilizing best practice methodology for performance improvement. The Consultant will be included in all regulatory and accreditation visits and be present when possible in order to identify issues and work with areas to ensure action plans meet guidelines and timeframes. The consultant will also be responsible for maintaining the regulatory and accreditation data base that tracks all site visits, mail requests, the issues involved, the responses and action plan compliance.

Education:

• Bachelor's degree (Field of study - nursing or business) - REQUIRED
• Will accept an Associate's degree or diploma nurse with 5 years of regulatory experience in lieu of Bachelor's degree
• Master's degree (Field of study - Nursing or business) - PREFERRED

Licensure:

• RN - REQUIRED
• CJCP (Certified Joint Commission Professional) -OR- HACP (Healthcare Accredited Certified Professional) - Must obtain within one year of hire/transfer date - REQUIRED
• CJCP - PREFERRED
• HACP - PREFERRED
• Existing coordinators must obtain one of the above certifications within 2 years of this update
• CPHQ (Certified Professional in Healthcare Quality) - PREFERRED
• BLS (Basic Life Support) - PREFERRED
• Lean Six Sigma - PREFERRED

Minimum Experience Required:

• 5 years of clinical experience plus 7 years of regulatory experience in healthcare including 3 years of Quality & Patient Safety Specialist level experience, including peer review and medical staff quality and patient safety and prior regulatory and tracer experience, or actual agency survey experience
• Excellent team building, communication and presentation skill
• Strong Microsoft Office skill
• Strong critical thinking skill
• Strong consulting skills, including team building, identifying opportunities for improvement, collaboratively working with leadership to create realistic and manageable action plans.