Covenant Health

Regulatory Specialist, Quality Management 

Part Time, 48 Hours Per Pay Period, Day Shift

Fort Loudoun Medical Center is equipped with a team of more than 200 doctors in more than 29 specialty areas. Our 87,000-square-foot hospital features advanced technology, including state-of-the-art Magnetic Resonance Imaging (MRI), Computerized Tomography (CT), Ultrasound, Diagnostic X-Rays and Women’s Imaging Services, as well as Nuclear Medicine technology unique to our surrounding counties. The physicians, staff and volunteers of Fort Loudoun Medical Center are dedicated to providing excellent care to every patient, every time.

Position Summary:

Reporting to the Chief Nursing Officer, 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 is responsible for maintaining current knowledge of all applicable regulations and providing regular educational updates on new and problematic standards to leadership, the facility regulatory specialists and applicable stakeholders. Coordinates the maintenance of the Continuous Survey Readiness (CSR) contracts providing guidance to best utilize educational resources. Oversees timely submission of updates for The Joint Commission applications. Coordinates mock survey activities to promote continuous survey readiness and ongoing regulatory compliance. Actively participates in System activities to support shared learning and regulatory compliance throughout the Health System.

Recruiter: Erin Wood || apply@covhlth.com

• Provides direction and support to organizational leaders and staff in all areas of regulatory compliance through training and the review, summarization and dissemination of all updates.
• Develops, implements, and maintains a variety of specific plans and processes, addressing related administrative issues that may be linked to program and project responsibilities and coordinates actions with other operational groups such as Chief Nursing Officers, Information Systems, Infection Preventionists, Facility Management, and Facility Senior Leader Teams, etc.
• Serves on the System Policy and Procedure Committee to ensure policy complies with regulatory/licensing standards.
• Develops and implements educational programs to ensure successful completion of survey visits.
• Implements processes and audits to ensure facility remains in a state of continuous readiness.
• Keeps leadership apprised of new and/or problematic standards as well as any issues identified at the local level.
• Ensures the completion of an FMEA as necessary to meet regulatory requirements.
• Directs the activity related to yearly focused standard review and is responsible for overseeing the completion and submission.
• Determines schedules and oversees completion of tracer activities and mock surveys on a regular basis.
• Works in collaboration with Regulatory Specialist for Engineering and Human Resources, site Safety Teams, Infection Prevention Teams, Medical Staff Office and Environment of Care Teams to ensure coordination or continuous survey readiness through regulatory compliance.
• Works directly with the Corporate Director of Quality Analytics and Regulatory Compliance to ensure system safety and reliability.
• Represents the facility onsite during any Joint Commission or CMS survey. Assists with State visits as deemed necessary by Administration.
• Local travel required.
• Follows policies, procedures, and safety standards. Completes required education assignments annually. Works toward achieving goals and objectives, and participates in quality improvement initiatives as requested.
• Performs other duties as assigned.

Minimum Education:          

Bachelor’s degree in Nursing or related health care field; Master’s preferred.

Minimum Experience:        

Five (5) years’ experience in a hospital. Able to demonstrate a working Knowledge of Joint Commission standards and Medicare Conditions of Participation. Previous experience in overseeing regulatory compliance in a facility preferred. Proficient in the use of Microsoft Office applications. Excellent organizational and communication skills required.

Licensure Requirement:     

Licensed in the state of Tennessee as required by bachelor’s degree. Employee must have a valid Tennessee driver’s license and state mandated Insurance coverage. Driving record must meet Covenant Health minimum standards at the date of hire and throughout employment tenure.