Clinical Regulatory Readiness Manager

Summary of Position: 

 Clinical Regulatory Readiness position supports the organization, the leaders and staff to be compliant to regulatory policy and procedure , assisting leaders to meet all clinical standards; state, federal and accreditation requirements including but not limited to the Centers for Medicare and Medicaid (CMS) and the Joint Commission (JC), DNV, OSHA, CMS and DOH.

 In addition, this position will support the development of a standardized organizational dyad structure with the Policy and Regulatory Readiness Manager to ensure regulatory compliance.      

The Clinical Regulatory Readiness Manager supports the Policy and Regulatory Readiness Manager with a partnership in mock survey rounding, documentation of pre survey/ follow-up activities, critical notifications follow up, external regulatory alerts and educational material that is regulatory based. This role participates in patient safety rounding when required based on capacity. This role also participates actively in both conducting and coordinating in collaboration with the Executive Director of Medical Staff, Medical Education and Regulatory Affairs general orientation educational sessions, mock surveys, onsite survey coordination, offsite mock surveys, unannounced surveys and assists with the review of regulatory standard crosswalks for every dept. in the organization as required. The position will support the Policy and Regulatory Readiness role with coverage and as a resource when needed. The Clinical Regulatory Readiness Manager will support the medical staff peer review process, OPPE, review onboarding health immunization for all student rotations through medical education and become fluid in the use of Credential Stream privilege software.

Other functions as determined as regulatory program, NYS immunization reportable for non-employed medical staff as well as regulatory audits of NYS Medical Staff Licensure and DEA registration compliance.  The clinical Regulatory Readiness Manager will support when asked attendance to RCA, IRC and Medical Staff Committees for report out as requested.

Primary Job Responsibilities: 

• Responsible for supporting the organization-wide regulatory structure and processes.
• Supporting policy /coverage work when needed and be agile to move through the established process and upload policies timely for staff access.
• Collaborate with leadership and subject matter experts to develop and adhere to the established regulatory requirements for organizational compliance.
• Collaborate with medical staff affairs team to support OPPE clinical review process and peer review as required.     
• Acts as a resource and provides ongoing consultation and education of the patient care teams, with respect to the clinical application of regulatory tools.  Develops regulatory educational programs to address changes in regulatory program requirements or untoward trends identified.  
• Assimilation, analysis, and presentation of data related to survey trends, mock survey trends and or patterns and concerns identified through reviews, mock tracers, survey or other concerns. Prepares user friendly reports, graphs and charts to facilitate best practice solutions and/ or improvement strategy implementation. Prepares all assigned department, committee/subcommittee as assigned or Team agendas and ensures all required materials and records are available and maintains accurate documentation of findings, conclusions, recommended actions and follow-up in the minutes of each meeting. 
• Presents consultative in all clinical work inclusive of mock survey and regulatory education, partnering with teams to support best practice and facilitate solutions to identified trends.

• Assists with overall regulatory program management and maintains current working knowledge of with the Hospital’s, CMS, TJC, DOH, DNV by-laws, regulatory theory and standards knowledge. 

Minimum Qualifications: RN Licensure required; bachelor’s degree preferred. Previous experience or training with clinical regulatory management and or coordination. Experience with web-based applications required. Experience with electronic/hybrid medical records Meditech, Medent and EPIC experience preferred. 1-3 years’ of hospital regulatory experience or specifically related to clinical regulatory, policy familiarity, MCN Policy Manager experience preferred.

Salary Range:
Pay Grade:
Compensation may vary based upon, but not limited to: overall experience and qualifications, shift, and location.