Signature Healthcare Regulatory Compliance Manager in Brockton, Massachusetts
Under the general supervision of the Director of Quality Resources, the Manager Regulatory Compliance is responsible to coordinate and oversee organizational activities related to compliance with standards applied by The Joint Commission (TJC) and the Center for Medicare and Medicaid Services (CMS). This individual is responsible for interpreting licensure, regulatory, and accrediting requirements and for assessing the organization’s current compliance. This Manager provides direct support and consultative services at the organization and department level to meet accreditation and regulatory standards. This individual is responsible for developing and monitoring action plans for continuous survey readiness. The Manager coordinates TJC compliance activities with the Hospital’s Joint Commission Steering Committee. This individual also maintains TJC accreditation software and assures timely data transfers as required. This individual is also responsible for the management of the hospital’s electronic occurrence reporting system. This system provides quality and safety information that is utilized for general risk management purposes and identifies possible quality and safety gaps with regulatory and accreditation compliance. The Manager also provides support for the organization’s safety program, proactive risk assessment and root cause analysis processes that align with TJC and CMS standards. This Manager also assists with regulatory reporting under the direction of the Director and VP Quality/CQO.
BS in Nursing required. Master’s degree in a healthcare related field preferred. Minimum of five years nursing experience, preferably in an acute care hospital setting. Minimum 3 years experience in healthcare quality and/or regulatory compliance (preferably TJC coordination).