ACCREDITATION AND REGULATORY READINESS SPECIALIST

ACCREDITATION AND REGULATORY READINESS SPECIALIST

Summary Summary:

The Accreditation and Regulatory Readiness Specialist is responsible for leading system-wide activities to evaluate and improve adherence to The Joint Commission (TJC) accreditation standards and CMS Conditions of Participation (CoPs) as well as other state and federal regulatory agencies. This includes facilitating and ensuring ongoing readiness for accreditation surveys as well as regulatory complaint investigations.

Responsibilities:

Ensures compliance with ongoing regulatory readiness. Serve as a resource for interpretation of regulatory, accreditation and certification standards (as applicable). Interpretation of relevance of standards in relation to hospital and clinic policies and practices. Conducts patient and system tracers in patient care areas through observation of practice. Participates in improving organizational performance through improvement activities and process engineering. Assists in the development of action plans with all levels of organizational leadership. Provides orientation to regulatory requirements and the LifeBridge Regulatory Readiness program for new leaders and staff members. Supports Regulatory Readiness & Accreditation Committee meetings and ad hoc workgroups created to address areas of non-compliance. Maintains a system for organizing and tracking compliance with required documents. Maintains tracer database and sources of information for accreditation and regulatory readiness activities. Collects, analyzes and reports data in support of continuous readiness activities. Facilitates concurrent and closed medical record review audits to assist in determining compliance with accreditation and regulatory requirements. Disseminates the results of compliance audits, and tracks follow-up on non-compliance and performance improvement efforts. Assists in assuring accuracy and timeliness of submissions to regulatory agencies. Maintains professional knowledge of regulatory requirements from external agencies, along with best practices, and shares this information within LifeBridge Health. Assists with external agency reviews & on-site surveys as needed. Educates staff on regulatory requirements, how to identify non-compliance, how to escalate concerns with non-compliance, and on problem-solving techniques for regaining and maintaining on-going compliance. Ensure compliance with regulatory agencies including meeting deadlines, when applicable.

Experience:

5-7 years

Education:

Bachelor's Degree Preferred Licenses And Certification:

Healthcare Related License Preferred Additional Information Who We Are:

LifeBridge Health is a dynamic, purpose-driven health system redefining care delivery across the mid-Atlantic and beyond, anchored by our mission to "improve the health of people in the communities we serve." Join us to advance health access, elevate patient experiences, and contribute to a system that values bold ideas and community-centered care.

What We Offer:

Impact:

Join a team that values innovation and outcomes, delivering life-saving care to our youngest and most vulnerable patients.

Growth :

Opportunities for professional development, including tuition reimbursement and developing foundational skills for neonatal critical care leadership and advanced certification.

Support:

A culture of collaboration with resources like unit-based practice councils and advanced clinical education support — improving both workflow efficiency and patient outcomes and allowing you to work at the top of your license.

Benefits :

Competitive compensation (additional compensation such as overtime, shift differentials, premium pay, and bonuses may apply depending on job), comprehensive health plans, free parking, and wellness programs. Why LifeBridge Health? With over 14,000 employees, 130 care locations, and two million annual patient encounters, we combine strategic growth, innovation, and deep community commitment to deliver exceptional care anchored by five leading centers in the Baltimore region: Sinai Hospital of Baltimore, Grace Medical Center, Northwest Hospital, Carroll Hospital, and Levindale Hebrew Geriatric Center and Hospital. Our organization thrives on a culture of

CARE BRAVELY

—where compassion, courage, and urgency drive every decision, empowering teams to shape the future of healthcare. LifeBridge Health complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex or sexual orientation and gender identity/expression. LifeBridge Health does not exclude people or treat them differently because of race, color, national origin, age, disability, sex or sexual orientation and gender identity/expression.