Regulatory Specialist

Reporting to the Director of Regulatory Compliance, the Regulatory Specialist assists with the design and implementation of the organization's regulatory compliance initiatives in accordance with the MedStar Health quality and safety goals and the Medstar Washington Hospital Center Quality and Safety Plan. Assists with designing, planning, organizing, coordinating and evaluating organizational efforts to achieve regulatory compliance and clinical quality improvement through the identification and promotion of best practices that ensure quality care and patient safety. Promotes a continuous readiness program that emphasizes quality and patient safety at the forefront of regulatory compliance. Under the direction of the Director of Regulatory Compliance, oversees the day-to-day program operations and workflow. Collaborates with Quality Managers and the organization's content experts, leadership, and medical staff leaders to develop an effective continuous readiness infrastructure that ensures the program and organizational goals are sustained. Explores opportunities for expanding and standardizing continual readiness initiatives throughout Medstar Washington Hospital Center.
Education

• Bachelor's degree in nursing, healthcare administration, or other related health care field required
• Master's degree preferred

Experience

• 3-4 years Experience with accreditation and regulatory standards and activities, including the survey process and follow up of corrective action plans. Knowledge of regulatory environment including The Joint Commission, CMS, DC Health required
• Experience in evaluating and monitoring compliance with regulatory standards through ongoing organizational assessment, i.e. Intracycle Monitoring, Focused Standards Assessment, tracers, mock surveys and measurement data. required

Licenses and Certifications

• CPHQ - Certified Professional in Healthcare Quality preferred
• RN - Registered Nurse - State Licensure and/or Compact State Licensure (If applicable) preferred

Knowledge, Skills, and Abilities

• Knowledge of current trends and best practices in quality, regulatory, performance improvement and patient safety
• Proven track record of building and maintaining team oriented working relationships with medical and other health professionals
• Excellent written and verbal communication skills

Promotes a safety culture in which clinical quality and patient safety programs are aligned with evidenced based best practices and High Reliability Organization (HRO) characteristics and principles.

Assists Director of Regulatory Compliance with the design, implementation and evaluation of regulatory programs in accordance with internal (entity and enterprise) and external (other healthcare agencies and organizations) requirements.

Assists the Director of Regulatory Compliance with facilitating key hospital strategic clinical regulatory initiatives.

Assists in survey preparation, including taking an active role during regulatory survey, assisting in writing action plans and follow up audits

Participates, develops and manages meetings and activities of the Accreditation and Regulatory Readiness Committees.

Ensures regulatory resources are up to date, such as Joint Commission Resources (JCR) software program, E-dition standards, and links to the CMS CoPs Interpretive Guidelines and other applicable regulations.

Facilitates, develops, and implements special projects as assigned.

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