Senior Director, Regulatory and Accreditation Compliance

As the Senior Director of Regulatory and Compliance, you will be responsible for development, support, training and fostering expertise in Survey Management by leveraging subject matter expertise in key clinical areas to support hospital survey readiness and high reliability principles. Under the direction of the DVP Quality Systems and Accreditation and in collaboration with Division Management and hospital executive teams, develops core standardized survey practices that promote clinical excellence, safety and regulatory readiness to achieve the mission, vision and goals established by Scion Healthcare. Provides support to facilities to implement established standards of care and high reliability practices as it relates to survey findings.    

Essential Functions: 
⦁    Functions as first line of support to hospital leadership for coordination of ongoing proactive survey readiness and survey response. Proactivity and routine assessment of regulatory readiness is the underpinning of this position’s mission. 

⦁    Provides subject matter expertise in conducting Survey Readiness Assessments (SRA) for Scion Health facilities in preparation for TJC triennial and CMS surveys. 

⦁    Provides education, training and functions as a resource to Support Center, Division/District and facility staff in specific areas that include clinical subject matter expertise relating to survey readiness and management.  

⦁    Functions as subject matter expert in oversight, writing and completion of Plans of Correction (POC) in response to results of TJC and CMS surveys. Guides hospitals in follow through and sustainment of POC, despite whether that POC is a result of internal or external survey. 

⦁    Teaches hospital leaders how to prioritize survey findings to those that are critical to patient safety and future survey compliance. 
⦁    Collaborates with facility-level leadership on all aspects of survey management; from the time the exit conference is conducted to the clearance of high risk survey findings, including the writing of a plan of correction in response to a statement of deficiences.
⦁    Maintains survey tracker and archiving survey documents for Scion Health. 
⦁    Regularly audits thoroughness and effectiveness of documentation as a way to evaluate proactive survey compliant practices.  
⦁    Monitors standards of care opportunities identified during survey readiness assessment, works with clinical operations team and hospital leadership to create output from these learnings, including, for example, updated policy and guidance statements, education materials, training sessions, etc. 
⦁    Assesses high reliability practices through on-site surveys and review of outcomes; provides education/support to facilities in their journey to reduce harm and foster high reliability. 
⦁    Completes special project requests timely as directed by the  DVP Quality Systems and Accreditation in collaboration with Vice President of Clinical Operations to accomplish Division/District needs.

 
 Job Specific Knowledge/Skills/Abilities/Expectations:

⦁    Excellent organizational skills.
⦁    Strong team-oriented approach. 
⦁    Excellent conflict resolution skills.
⦁    Excellent investigative skills.
⦁    Strong knowledge of regulatory requirements for healthcare.
⦁    Work independently with minimum supervision.
⦁    Excellent oral and written communication and interpersonal skills.
⦁    Ability to work under stress and in emergency situations.
⦁    Strong knowledge of Microsoft Office Suite products; especially word processing and spreadsheet software.
⦁    Ability to be flexible in use of all forms of medical records (paper and electronic).
⦁    Must read, write and speak fluent English. 
⦁    Approximate percentage of time required to travel: 75%
⦁    Performs other related duties as assigned.

Qualifications:
⦁    Education:  Bachelor’s degree in nursing required; Master’s degree in Healthcare related  field preferred.                
⦁    Licenses/Certification: Registered Nurse required, CPPS preferred  
Experience: 
⦁    Minimum five years’ experience in clinical management and leadership positions.
⦁    Experience in hospital setting with multi-facility responsibilities and nurse executive experience, including participation in regulatory management preferred.  Subject matter expertise in ICU, cardiac, Med/Surg, Peri-operative, Maternal-child, Infection Control,
⦁    Emergency or Radiology product lines preferred.