Director of Regulatory Affairs, Regulatory Affairs

Department:
Regulatory Affairs

Address: 1611 NW 12th Ave, Miami, Florida, 33136

Shift details:
Monday‑Friday 8:30 am‑5:00 pm

Jackson Health System is a nationally and internationally recognized academic medical system offering world‑class care to any person who walks through our doors. For more than 100 years, Jackson has evolved into one of the world’s top medical providers for all levels of care, no matter if it’s for a routine patient visit or for a lifesaving procedure. With more than 2,000 licensed beds, we are also proud of our role as the primary teaching hospital for the University of Miami Miller School of Medicine.

Here, the best people come together to deliver Jackson’s mission for our diverse communities. Our employees are committed to providing the best CARE by demonstrating compassion, accountability, respect, and expertise in everything we do.

The Director of Regulatory Affairs is a member of the leadership team who is responsible for the organization‑wide oversight and resolution of regulatory and hospital licensure matters including process changes, new requirements, and compliance with all regulatory standards required for patient safety and quality of care and services and promotion of continuous survey readiness. The incumbent may directly interface with regulatory authorities on specific projects or products to ensure that JHS is adhering to all applicable government regulations and successfully manage multiple projects simultaneously while adapting to changing project priorities.

• Manages confidential information within the department and related involved employees, patients, visitors, and/or physicians.
• Responsible for the organization‑wide oversight and resolution of regulatory and hospital licensure matters including survey preparation, process changes, new requirements, and compliance with all regulatory standards required for patient safety and quality of care and services.
• Provide organizational support to the Corporate Director of Regulatory Affairs to ensure effective communication and oversight of the organizational responses to unannounced regulatory visits and inspections and timely completion and submission of licenses, applications, certification, and accreditation documentation.
• Assist facility in preparations for surveys (i.e., State, The Joint Commission, Center for Medicare and Medicaid Services, AHCA), conduct quality and patient safety surveys, and ensure continuous readiness for State and Federal surveys.
• Lead or organize tracers/mock surveys with the interdisciplinary team to assess, drive, and maintain continuous survey readiness, communicate findings and concerns, and follow up on action plans across the organization.
• Participate in organization‑wide committees and administrative meetings of various departments and campuses as necessary to address regulatory standards or concerns and relate information to various disciplines as appropriate.
• Collaborates with Risk Management in the facilitation of root cause analysis (RCA), failure mode and effects analysis (FMEA) and monitoring of action plan implementation.
• Serve as a liaison with various regulatory agencies and entities for matters on program/hospital/system wide accreditation and licensure and/or certifications.
• Collaborate with the leadership at different levels throughout the organization in establishing and prioritizing goals and actions, process improvements on deficiencies and significant findings relevant to patient safety and quality of care.
• Coordinates the development of data collection tools and review of data. Lead, coordinate, investigate, and respond to complaint and/or quality concerns received via Federal and State agencies and related entities.
• Collaboration with Risk Management in relation to incidents that may result in regulatory visits and/or sentinel event reporting.
• Maintain regulatory and other hospital survey readiness and compliance data collection systems with oversight of audit tools and results for continuous compliance and develop statistical and qualitative reports on monthly/quarterly basis…