ACCREDITATION / REGULATORY MARKET DIRECTOR
Base Salary $140-200K+ Annual Incentive Opportunity + Full Benefits.
**MA State RN License Required
This position oversees the regulatory and accreditation activity for the Massachusetts Market.
Summary
The Accreditation/Regulatory Market Director is responsible for ensuring all Massachusetts market hospitals and associated outpatient settings are continuously compliant with regulatory standards and continuously ready for accreditation surveys.
Roles and Responsibilities
Reports to Group Chief Nurse Officer on activities and initiatives, including escalating issues or concerns related to survey readiness.
Partner and collaborate with Market Director of Quality, hospital level Directors of Quality, CNOs, Infection Prevention Managers and Risk Managers for all regulatory and accreditation activity.
Specific Position Accountabilities
- Assists all MA Market hospitals and impacted outpatient settings with the coordination of The Joint Commission (TJC) and specialty accreditations preparedness including designing and maintaining the hospital’s tracer system.
- Monitors market wide preparedness through use of AMP data analytics. Uses the analytics to strategically and tactically design and lead the MA market regulatory and accreditation work.
- Leads and participates in committee meetings accordingly.
- Coordinates TJC triennial surveys, Tenet CCA surveys and survey follow-up activity.
- Responsible for complying with all policies and procedures that pertain to HIPAA including the minimum necessary requirements for this position.
- Performs and fulfills all HICS (hospital incident command system) responsibilities, assignments, tasks and roles as directed and needed by the facility in times of emergency and/or disaster. Responsible for knowing the hospital emergency codes, including the purpose and appropriate action for each and adheres to the Hospital’s policies and procedures for each emergency code.
Education
- Bachelor’s Degree in Nursing, related field or equivalent competencies/job expertise.
- Master’s Degree in Nursing, Education, Management or related field or demonstrated equivalent competencies is preferred.
Experience
- Minimum two (2) years in leadership role and/or quality management role. Experiences includes specific responsibilities for quality assurance, educational or accreditation activities.
- Should be PC literate, knowledgeable of Microsoft Office and database applications.
- Required: Registered Nurse in the State of Massachusetts.
- Knowledge of accreditation, safety and regulatory requirements is necessary.
