Director, Accreditation and Regulatory Affairs

Job description

PURPOSE: This position is accountable for working with the senior leadership in developing, implementing, monitoring, and evaluating the Regulatory Compliance Program for the hospital and the medical group. This position ensures that we are always in compliance with applicable laws, the public health code, regulations, and standards.
SCHEDULE: Full time, 80 hours every two weeks, primarily 7:30 am to 4:00 pm, must be able to work other shifts including weekends and holidays to accommodate organizational needs, 30-minute unpaid meal break.
SUPERVISOR : Direct report to the President of UCHC Waterbury Hospital and matrix into COO/CNO of UConn Health.
PRINCIPAL DUTIES AND ACCOUNTABILITIES:
• Maintains a current understanding of regulatory and clinical quality trends and changes in law and advises appropriate management staff of trends affecting their activities.
• Serves as a regulatory consultant and content expert to the President, CNO, CMO, nursing, physicians, CNSs, nurse managers, staff, and students to positively impact compliance with laws and regulations.
• Manages in daily work including, but not limited to, mock tracers, adverse event reporting, contract quality metrics, continuous readiness, unannounced rounding, deficiency tracking, action plan accountability, CMS emergency preparedness conditions of participation, and reporting and certification preparation.
• Responds to reports of regulatory and clinical quality compliance problems or concerns. These include CMS compliance, DPH investigations, patient grievances, ombudsman coordination and regulator response coordination overall.
• Represents the Hospital to external parties/regulatory bodies/governmental agencies.
• Collaborates and participates in sentinel event reporting procedures.
• Conducts root cause analyses.
• Supports AI/technology regulatory oversight including clinical documentation compliance, AI governance implications, telehealth regulatory compliance, cybersecurity-related regulatory preparedness.
• Responsible ensuring the integrity of data reported to the state and national agencies (example CMS, DPH).
• Investigates alleged regulatory compliance violations as assigned in coordination with other departments.
• Understand and uses risk heat maps, escalation pathways, board reporting and risk prioritization methodology as needed.
• Responsible for assisting leadership with coordination of UCHC Waterbury response and corrective action plans to the Regulatory Violations and Citations by working with other departments to accomplish the required action items.
• Ensures that the principles of sound compliance with applicable laws, regulations and standards are maintained.
• Identifies potential or existing risks or liabilities relating to the respective programs and making appropriate recommendations to maintain compliance and avoid risk.
• Leads the survey readiness assessment analysis.
• Develops, Reviews interprets and implements established and new policies, standards, and procedures to assure congruence with current regulations. Oversees centralized policy governance, policy and procedures review cadence, policy harmonization and our electronic policy management system.
• Develops educational programs related to regulatory and clinical quality compliance issues.
• Responsible for review and reporting of all adverse events and maintenance of the adverse event documentation system.
• Oversees, monitors, and tracks the Environment of Care readiness. This includes utilities, fire/life safety, ligature risk, construction risk, interim life safety measures.
• Prepares all areas for accreditation and licensure surveys and supports certification for individual programs.
• Works with supervisor to lead the Workplace Violence Program. Including OSHA compliance, staff injury trends, violence prevention metrics, behavioral emergency response systems.
• Serves on various committees as requested and represents the organization at CHA.
• Other duties, as necessary.

MINIMUM QUALIFICATIONS REQUIRED:
KNOWLEDGE. SKILL & ABILITY:
Excellent knowledge of state and federal regulatory requirements specific to Healthcare; knowledge of regulatory standards; demonstrated leadership ability; risk management and performance improvement skills; excellent knowledge of high reliability process, and excellent analytical and organization skills; deductive thinking skills; excellent oral and written communication skills; advanced software and AI skills: excellent interpersonal skill; conflict resolution skills; ability to contribute to administrative activities as necessary; effective presentation skills; represents the office with regulators, agencies and others in an effective manner; ability to meet deadlines; adjust to changes in policies, procedures and priorities; knowledge of personnel and labor relations regulations.
EXPERIENCE & TRAINING:
• Bachelor’s degree in nursing, with a master’s degree in a related field, or enrollment in a master’s degree program.

PREFERRED QUALIFICATIONS:
• Inpatient hospital acute care Registered Nurse, APP or MD experience
• Four (4) years of Management, Director, or Hospital Regulatory experience
• Lean Six Sigma Black Belt or other related certification.