Position Summary The Accreditation and Regulatory Specialist serves as the expert resource on regulatory/ accreditation and licensure standards and expectations for compliance. Provides direction to hospital departments to achieve and maintain accreditation and licensure. Primary Position Responsibilities 1.Design and implement a systematic approach to ensure a high level of awareness of regulatory and accrediting agency requirements throughout the healthcare system 2.Ensures compliance with federal, state regulatory standards and licensing requirements, including Joint Commission readiness 3.Chairs Regulatory Readiness Committee 4.Coordinates site visits, follow-up reports, compliance activities 5.Conducts focused standards assessment and action plans related to such. 6.Assesses, monitors, and implements, as appropriate, activities and educational opportunities to maintain compliance with accreditation and/or regulatory standards 7.Trains current and new management staff on their role in accreditation and survey activities

Qualifications Minimum Education :

Required:

Bachelor's Degree in Nursing or a healthcare related field

Preferred:

None Minimum Years of Experience (Amount, Type and Variation) :

Required:

A minimum of 3 years of current experience in TJC hospital accreditation and compliance to include regulatory survey coordination experience

Preferred:

License, Registry or Certification :

Required:

None Preferred:

Active NJ RN License, Certified Professional in Healthcare Quality, (CPHQ), Certified Joint Commission Professional, (CJCP) Knowledge, Skills and/or

Abilities :

Required:

Experience in project management, group facilitation, and leadership group presentations Knowledge and experience in process improvement methodologies Excellent verbal/written communication, interpersonal, and relationship-building skills Must possess a solid understanding of team dynamics Self-directed, highly motivated with superb problem-solving abilities Advanced computer skills to maintain databases, spreadsheets and develop reporting tools/graphs/control charts

Preferred:

None Hunterdon Health is committed to providing a competitive benefit package to our employees. Benefit offerings vary based on status and may include but not be limited to medical, dental, vision, family forming, paid time off, tuition reimbursement, and retirement savings. The hiring range listed is the potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement. When determining an applicant's hourly rate and/or base salary, several factors may be considered as applicable (e.g., years of relevant experience, education, internal equity, and specialty).

Location:

HHS Hunterdon Healthcare System Inc.

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Quality Improvement Schedule:

Full-time, Day shift, M-F, day shift