Dir Clin/Reg Affairs Position Available In Shelby, Tennessee

At Regional One Health, we are committed to providing exceptional, compassionate care and that starts with a foundation of regulatory excellence. Join a team where your expertise in clinical compliance, accreditation standards, and risk management directly contributes to the safety and quality of care we deliver daily. In this leadership role, you will champion a culture of continuous readiness, support interdisciplinary collaboration, and ensure we exceed the expectations of regulatory agencies while staying mission-focused on improving the health and well-being of our community. This is more than compliance, this is purpose-driven leadership at its best. Responsible for the management of clinical/regulatory and continuous readiness activities organizational-wide, which include Joint Commission (JC), Centers for Medicare/Medicaid Services (CMS), Tennessee Department of Health, clinical risk management, infection control, clinical database systems and occupational health services, to ensure compliance with standards/elements of performance, core measures, performance review activities, and other organizational, state, federal, and local regulatory laws, standards, and protocols. Works collaboratively with internal staff/external agencies/organizations for facilitation, coordination, integration, and follow up of clinical/regulatory operations and continuous readiness activities. Provides follow-up to medical staff issues and processes to ensure compliance, communication and facilitation of necessary information through appropriate levels of the organization. Apprise Vice President of all activities, pertinent changes in internal/external market, threats, and opportunities in a timely and anticipatory manner and presents action plans for immediate implementation/approval. Provides leadership and operationally implements plans, programs, and activities to ensure continuous readiness and in compliance with organizational, state, federal and local regulatory laws and standards and practices. Reviews compliance with patient care standards as it relates to the care provided to patients ranging from neonates to geriatrics. Develops and manages systems for ongoing monitoring, evaluating and reporting compliance of Joint Commission and other regulatory requirements, pursues opportunities to improve patient care and reports identified problems for resolution. Communicates appropriately and makes recommendations as needed to improve services and efficiency in operations. Participates on departmental/organizational committees serving as a resource related to Joint Commission, CMS, state, federal, and local regulatory laws, standards, and practices. Consults, advises and provides assistance to internal/medical staff departments/committees and organizational departments/committees in the development and management of clinical and regulatory affairs activities to ensue quality patient care and meet Joint Commission standards and other regulatory requirements. Provides interpretation of Joint Commission, CMS, TN Dept. of Health, and other regulatory standards to promote consistency and understanding throughout the organization. Assures accurate and timely communication with federal/state agencies and accrediting organizations for compliance and operational issues. Responds to, coordinates and provides assistance with all local, state, federal and accrediting institutions on-site visits, coordinating activities and follow-up to ensure timely completion and resolution of identified issues. Maintains results and current status of all surveys/visits. Coordinates investigations related to local, state, federal and accrediting institutions and regulatory agency requirements. Provides communication and documentation related to results of surveys, licensing and accrediting requirements. Attends Medical Staff committee meetings providing administrative support, assisting with problem resolution and communication across organization/department of appropriate issues and concerns. Provides feedback, information and decisions to direct reports to assure rapid response to internal/external market changes, opportunities and threats and provides support for compliance and operational issues. Maintains documentation of all licensing and accrediting requirements for: Joint Commission, OSHA, TN

OSHA, CAP, FDA, FAA, TN

Board of Pharmacies, Residency Accreditation, and all state and local accrediting institutions and regulatory agencies. Qualifications Master’s Degree in nursing, health information management, healthcare administration or other related discipline Required Minimum 5 years experience progressive administrative/management experience with experience in performance review or related clinical/regulatory field Required Physical Demands Standing

• Occasionally Walking
• Occasionally Sitting
• Constantly Lifting
• Rarely Carrying
• Rarely Pushing
• Rarely Pulling
• Rarely Climbing
• Rarely Balancing
• Rarely Stooping
• Rarely Kneeling
• Rarely Crouching
• Rarely Crawling
• Rarely Reaching
• Rarely Handling
• Occasionally Grasping
• Occasionally Feeling
• Rarely Talking
• Constantly Hearing
• Constantly Repetitive Motions
• Frequently Eye/Hand/Foot Coordination
• Frequently