Regulatory Coordinator - Full-time / Part-time

It's More Than a Job, it's a calling

Title: Regulatory Coordinator

Location: Advocate Good Shepherd Hospital, Barrington

Hours: Full Time, Salaried

Shift: Day

JOB and UNIT SUMMARY:

The Regulatory Coordinator is responsible for the management, coordination and integration of regulatory functions at Advocate Good Shepherd Hospital, including its offsite campuses. This individual will oversee, coordinate and perform regulatory activities to ensure full and constant compliance with regulatory agencies such as Det Norske Veritas (DNV), including National Integrated Accreditation for Healthcare Organizations (NIAHO) and ISO Standards, The Accrediting Organization (Accrediting Organization) Centers for Medicare and Medicaid Services (CMS), the Illinois Department of Public Health (IDPH) Occupational Safety and Health Administration (OSHA), Food and Drug Administration (FDA) and disease specific accreditations such as Stroke, Level II Trauma, Emergency Department Approved for Pediatrics (EDAP), and others. This individual will lead the Quality Management System (QMS) Audit Program will identifying nonconformities, opportunities for improvement, and addressing with effective corrective action plans. This individual with demonstrate the ability to assess the organization's effectiveness of the QMS and outcomes that affect the quality of patient care in accordance with regulatory and accreditation standards.

REQUIRED QUALIFICATIONS:

• Bachelor's Degree in healthcare related field
• Minimum four years' experience working in the healthcare system
• Demonstrated educational, managerial and/or leadership ability
• Demonstrated project management expertise
• Ability to use and manage technology as needed
• Process/Performance Improvement knowledge
• Excellent organizational skills
• Excellent interpersonal communication skills
• Resiliency and flexibility to work within a rapidly changing environment
• Ability to travel to other Advocate Good Shepherd Hospital sites.
• Urgent/emergency responsiveness to regulatory visits and requests
• Expertise in relationship building with both internal and external customers (regulatory surveyors)
• Expert organizational skills
• Impeccable attention to detail
• Ability to meet extremely tight deadlines for regulatory response

Accountabilities:

Responsible for professional and personal growth and development

Provides oversight, direction, coordination for constant survey readiness and compliance with DNV (NIAHO and ISO Standards), Accrediting Organization, CMS, OSHA, IDPH, and other regulatory agencies.

Facilitates the coordination of all survey visits, both unannounced and scheduled, by regulatory agencies.

Develops processes and mechanisms to monitor accreditation compliance as it relates to plans of correction for identified deficiencies.

Assures and participates in the process for review and revision of house wide policies to ensure all policies are current in accordance with regulatory and accrediting agencies.

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