Director, Regional Regulatory - Clinical Regulatory Compliance - Full

Up to a $25,000 sign on bonus.The pay range for this role is $40.25-62.59.Position Summary:Provides leadership to the organization relative to Clinical Regulatory Compliance program which assures the implementation and oversight of clinical requirements developed by Center for Medicare and Medicaid (CMS), the Department of Health (DOH), and The Joint Commission (TJC). The primary purpose of the Clinical Regulatory Compliance Program is to ensure that the hospital's policies and practices comply with the requirements of external organizations that regulate or accredit the hospital, and to monitor the organization's compliance with its own policies.

This function is distinct from the compliance program that operates under the authority of the Compliance Officer.

Provide leadership to include the assessment, development and evaluations of programs related to staff education for all staff throughout the facility.Education, License & Cert:Bachelor’s degree in Nursing.

A Master’s degree, in Education or Nursing, is preferred.

Licensed Registered Nurse in the appropriate state.Experience:Minimum of five years acute hospital experience.

Prior experience in leadership/management desired.

Demonstrated effective communications, critical thinking/problem solving skills required.Essential Functions:1.

Assumes leadership responsibilities for the program including:a.

Goal setting, developing monitoring tools, status reportingb.

Organizing departmentc.

Budget planning and managementd.

Monitoring the work of others outside the departmente.

Utilizes data for decision making and strategic planning2.

Prepares reports to regulatory agencies on a timely basisa.

Submits required reports to external agenciesb.

Develops corrective action plans as requiredc.

Monitors and reports on the implementation of corrective action plans3.

Responsible for assuring that the organization complies with new clinical requirements announced by the Joint Commission, CMS, or the DOHa.

Ensure that the hospital's leadership is aware of new requirementsb.

Ensure that plans are developed and implemented to meet these requirementsc.

Ensure that newly implemented processes are integrated into ongoing management and operational activitiesd.

Ensures that effectiveness of regulatory action plans or new processes are monitored to evaluate compliancee.

Keeps hospital leaders and administration (including the Board) informed of regulatory findings and action plan progress via formal and/or informal reports on a regular basis4.

Demonstrates ability to be a person of influencea.

Builds trustb.

Provides leadership for implementing changes/performance improvement efforts, even though operational area may not directly report to this positionc.

Creates a work environment that enhances employee, patient and physician satisfactiond.

Sets performance expectations/goals and maintains high standards of performancee.

Collaborates with organizational line management to assure full compliance5.

Provides a consulting/facilitation role in the organization for performance improvement activities and processes.a.

Facilitates committees, teams and workgroupsb.

Supports medical staff initiativesc.

Assists in project development and managementd.

Assists in operationalizing electronic health record changes (i.e.

orders, documentation fields/screens) that are consistent with clinical regulations and hospital policies.Other Duties:1.

It is understood that this description is not intended to be all inclusive.

Other duties may be assigned as necessary.2.

Takes Administrator An Call assignment3.

Travel is required