Regulatory Specialist

Regulatory Specialist, Quality Management

Full Time, 80 Hours Per Pay Period, Day Shift

LeConte Medical Center is a part of Covenant Health, our region’s top-performing healthcare network and is a 79-bed community hospital located in the heart of Sevier County. We’re a full-service, not-for-profit hospital delivering modern medicine and compassionate care to the growing Sevier County community. LeConte offers a full range of health services, including top-tier specialists, a modern ER, and a beautiful Women’s Center.

Learn more about our amazing facility at

As you’d expect, we offer our employees a robust benefits package, including:

• unmatched medical insurance
• tuition reimbursement
• student loan repayment assistance
• certification bonuses
• leadership and professional development programs
• an employer-matched 401(k)
• a generous Combined Time Off (CTO) program

The Lab at LeConte Medical Center is a rewarding place to work. The skilled team of Sr. Lab Assistants, Lab Assistants, MTs, and MLTs work together to provide all laboratory services to LeConte patients in a timely manner. In this department, the staff is focused and goal-driven to provide accurate and sufficient results for the people they serve.

Reporting to the Quality Manager, this position is responsible for planning, budgeting, monitoring, and evaluating performance related to The Joint Commission, CMS, and other regulatory/licensing agencies. The Regulatory Specialist maintains current knowledge of all applicable regulations and provides regular educational updates on new and problematic standards to leadership, the facility Regulatory Specialists, and applicable stakeholders. Coordinates the maintenance of the CIHQ contract, guiding educational and mock survey resources, timely submission of updates and annual Joint Commission application for triennial survey, and any Joint Commission certifications.

Coordinates mock survey activities to promote continuous survey readiness and ongoing regulatory compliance. Leads, organizes, and follows up on opportunities identified in a monthly regulatory preparation meeting. Actively participates in System activities to support shared learning and regulatory compliance throughout the Health System. Directs all onsite survey activities including Joint Commission, CIHQ, state surveys, and other regulatory agencies.

Recruiter:
Alexa Robbins ||

• Provides direction and support to organizational leaders and staff in all areas of regulatory compliance through training and the review, summarization, and dissemination of updates.
• Develops, implements, and maintains specific plans and processes, addressing related administrative issues linked to program and project responsibilities, and coordinates actions with operational groups such as Chief Nursing Officers, Information Systems, Infection Preventionists, Facility Management, Facility Senior Leader Teams, etc.
• Responsible for organizing ongoing review of local policies, updating the local policy site, summarizing policy changes to leadership, and providing input on system policies related to regulatory functions.
• Collaborates with education to develop and implement educational programs to ensure successful completion of survey visits.
• Remains current with Joint Commission, CMS, and the state of Tennessee regulations in addition to applicable licensing requirements.
• Implements processes and internal audits to ensure the facility remains in a state of continuous readiness.
• Provides monthly updates, and as-needed updates, to leadership of any new or potential regulatory compliance concerns.
• Ensures completion of an FMEA at the facility level at least every 18 months.
• Directs yearly focused standards review and oversees the completion.
• Ensures education and use of Joint Commission Resources products in the facility.
• Determines schedules and oversees completion of tracer activities and mock surveys regularly.
• Works in collaboration with Regulatory Specialists for Engineering and Human Resources, Infection Prevention Teams, Medical Staff Office, and Environment of Care Teams to ensure coordination of…