Regulatory Specialist (S)

It's more than a career, it's a calling.

WI-SSM Health St. Mary's Hospital - Madison

Worker Type:

Regular

Job Summary:

Coordinates regulatory compliance activities. Works collaboratively with leaders, clinicians and other staff in the development and implementation of regulatory requirements to identify and reduce risks, and meet regulatory requirements. Ensures implementation of an integrated regulatory compliance and accreditation program.

Job Responsibilities and Requirements:

• Possesses a working knowledge of all The Joint Commission (TJC), Centers for Medicare & Medicaid Services (CMS) Conditions of Participation and State Hospital Licensing Act standards and regulations and stays current with changes to these standards and regulations.
• Reviews current standards and ensures awareness of new and revised standards. Possesses a working knowledge of organizational policies and procedures and assists with development and revision of Policies and Procedures to ensure compliance with hospital regulations.
• Maintains a state of continual readiness related to The Joint Commission (TJC), Centers for Medicare and Medicaid Services (CMS) Conditions of Participations (CoPs) and State specific regulations. Supports the hospital(s) using the SSM Regulatory Model Scope of Service approach and tools to ensure a state of constant readiness for survey and compliance laws and regulations.
• Provides education, consultation and interpretation of regulations and accreditation standards, with an emphasis on hospital, ambulatory and behavioral health standards and/or regulations.
• Assists in facilitating an integrated organizational approach to assessing and meeting regulatory requirements and process improvements. Supports and facilitates coordination of regulatory surveys for the outpatient and inpatient practice.
• Organizes and leads surveys at assigned ministry. Also provides ongoing support to other region ministries for survey activity and/or other compliance needs. Utilizes team leading and facilitation skills to support meetings, action plans, development of measures and goals, and data collection.
• Coordinates all hospital related regulatory inquiries. Facilitate all state, CMS, and TJC on-site visits and remote complaints/investigations. Responsible for developing and monitoring action plans to address compliance issues. Ensures all required regulatory related reports within the hospital and region are completed and submitted to regulatory agencies accurately and timely.
• Plans and implements systems for assessment and improvement of processes related to hospital operations to ensure regulatory compliance. Coordinates and facilitates hospital wide and clinic tracers. Gathers data from tracers and chart audits to create departmental scorecards related to key compliance issues. Communicates findings to administrative teams.
• Facilitates the completion of the annual Intracycle Monitoring (ICM), a complete gap analysis of compliance with TJC standards.  Works with leaders to develop, implement and monitor action plans for any identified non-compliance.
• Conducts investigations and audits to identify areas of risk. Drafts plans for improving compliance practices to address those risks, and monitors to ensure the program is following best practices and standards.
• Performs other duties as assigned.

• Bachelor's degree or equivalent combination of education and experience

• One year experience in related field

PHYSICAL REQUIREMENTS

• Frequent lifting/carrying and pushing/pulling objects weighing 0-25 lbs.
• Frequent sitting, standing, walking, reaching and repetitive foot/leg and hand/arm movements.
• Frequent use of vision and depth perception for distances near (20 inches or less) and far (20 feet or more) and to identify and distinguish colors.
• Frequent use of hearing and speech to share information through oral communication. Ability to hear alarms, malfunctioning machinery, etc.
• Frequent keyboard use/data entry.
• Occasional bending, stooping, kneeling, squatting, twisting and gripping.
• Occasional lifting/carrying and pushing/pulling objects weighing 25-50 lbs.
• Rare climbing.

REQUIRED PROFESSIONAL LICENSE AND/OR CERTIFICATIONS 

• None

Work Shift:

Day Shift (United States of America)

Employee

Department:

8754000033 Regulatory

Scheduled Weekly Hours:

40

Benefits:

SSM Health values our exceptional employees by offering a comprehensive benefits package to fit their needs.

• Paid Parental Leave: we offer eligible team members one week of paid parental leave for newborns or newly adopted children (pro-rated based on FTE). 

• Flexible Payment Options: our voluntary benefit offered through DailyPay offers eligible hourly team members instant access to their earned, unpaid base pay (fees may apply) before payday.

• Upfront Tuition Coverage: we provide upfront tuition coverage through FlexPath Funded for eligible team members. 

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SSM Health is an equal opportunity employer. SSM Health does not discriminate on the basis of race, color, religion, national origin, age, disability, sex, sexual orientation, gender identity, pregnancy, veteran status, or any other characteristic protected by applicable law. Click here to learn more.