Dir-Regulatory/Accr/Compliance

Education: Bachelor degree in health-related field.

Preferred Education: Masters in Health related field.

Experience: Minimum ten years health care experience in a clinical discipline including at least five years accreditation experience and 5 years leadership/management experience. Specific experience related to accreditation and regulatory bodies, such as CMS and state licensing agencies.

Other: In-depth knowledge of accrediting and regulatory standards with demonstrated ability to interpret standards, serve as a subject matter expert and communicate information to all levels in the organization.

Demonstrated leadership skills with the ability to manage co-workers and prioritize and manage multiple tasks simultaneously.

Excellent communication skills to effective interact with all levels of Caregivers, from senior leaders to front-line caregivers.

- Serve as the regional community primary contact to regulatory and accreditation organizations.
- Provide assistance with building Epic documentation modules to meet regulatory requirement sand key clinical activities.
- Keep abreast of changes in legislation and requirements related to regulatory accreditation and licensing issues.
- Develop a standard approach for assessingregulatory risk across the continuum of care and venues for both existing and new acquisitions.
- Identify key Joint Commission accreditation, CMS regulations and State licensing issues and defines areas for improvement.
- Bring a community view and expertise to patient safety and quality improvement activities thru regulatory activities.
- Provideguidance to ministry-wide andcommunity collaborative groups when appropriate.
- Monitor and provide oversight and review Quality and Safety goals during mock surveys.
- Implements a regional continuous readiness compliance program for all venues of care defining the team structure, process and assessment.
- Education and mentor new mock surveyors.
- Design and conduct on-site mock surveys using Mercy tracer tools and other tools to evaluate and maintain compliance.
- Provide formal training on Joint Commission standards and CMS regulations to organizations when appropriate.
- Identify vulnerability and direct strategies to enhance compliance.
- Share best practices across the region.
- Communicate across the regional community on a regular basis: compliance updates, activities and areas of focus.
- Collaborate and work with key stake holders on regulatory goals; working to develop written policies andprocedures to ensure compliance with regulations and standards.
- Support and assist with corrective action plans.
- Provide consultative services to all departments and services regarding the intent of regulations and strategies to maintain compliance.
- Performs other work duties as assigned.

From day one, Mercy offers outstanding benefits - including medical, dental, and vision coverage, paid time off, tuition support, and matched retirement plans for team members working 32+ hours per pay period.

Join a caring, collaborative team where your voice matters. At Mercy, you'll help shape the future of healthcare through innovation, technology, and compassion. As we grow, you'll grow with us.