RN Regulatory Program Coordinator

Summary

The Regulatory Program Coordinator serves as the expert resource on regulatory/accreditation and licensure standards and expectations for compliance. Designs and implements a systematic approach to ensure a high level of awareness of regulatory and accrediting agency requirements throughout the organization, including ramifications of failures in compliance. This position guides the development of policy and guidelines as they relate to the hospital and compliance with regulatory and accreditation guidelines, and assists in the interpretation of these policies.

• Provides central expertise regarding accreditation and licensure standards; identifies, plans for, communicates, monitors, and evaluates actions to comply with existing and new regulations, standards, and accreditation requirements throughout the organization. Duties include timely analysis of regulatory materials, journals, and newsletters for operational implications; development of working relationships with external agency representatives and key contacts; and attendance at appropriate educational programs.
• Provides leadership for organizational preparation and readiness for regulatory and accreditation surveys.
• Implements a periodic organizational needs assessment for regulatory compliance, including Intra‑cycle Monitoring (ICM) using the Focused Standards Assessment (FSA) Tool required by The Joint Commission.
• Identifies areas of vulnerability and assists area leaders in developing corrective action plans; also identifies and communicates areas of success to celebrate and promote best practices.
• Reviews, assesses, and works to revise relevant medical center policies and procedures and/or recommends and assists with the development of new policies and procedures to ensure compliance with regulatory, accreditation, and professional standards.
• Serves as an additional liaison with the Quality Director to regulatory agencies and accreditation bodies.
• Provides documentation and other information as required or requested on time to assure compliance for regulating and accreditation agencies, maintains and organizes all critical documentation support, and oversees the development of delivery and follow‑up documentation (reports, plans, appeals, measures, etc.).
• Manages all agency site visits, including scheduling, logistics, and communication within the organization.
• Provides consultation to all departments on the interpretation and application of TJC accreditation standards and CMS Conditions of Participation to maintain ongoing readiness.
• Develops mandatory educational material to meet periodic requirements and assists area leaders in developing specific educational material to address areas of vulnerability for compliance with standards or unique requirements for special accreditations.
• Assists the medical center in reviewing all educational materials for regulatory or accreditation compliance to assure they reflect medical center practice and are congruent with each other.
• Adheres to and supports team members in exhibiting TMCH values of integrity, community, compassion, and dedication.
• Adheres to TMCH organizational and department‑specific safety and confidentiality policies and standards.
• Performs related duties as assigned.

Education
:
Bachelor’s degree in nursing from an accredited institution. Master’s Degree preferred. An equivalent combination of relevant education and experience may be substituted for these educational requirements.

Experience
:
Five (5) years nursing experience in a hospital setting.

Licensure
:
Current RN licensure permitting work in the state of Arizona.

• Knowledge of regulatory requirements (TJC and CMS).
• Knowledge of the accreditation process.
• Knowledge of survey preparation and required follow‑up activities.
• Skill in written and oral communications.
• Skill in conducting mock regulatory surveys using the tracer methodology.
• Ability to interpret, prepare, and present reports to management in both written and oral formats.
• Ability to make presentations, design, and provide training/education to staff and management.