Regulatory Specialist

Regulatory Specialist

This role supports the coordination and facilitation of accreditation and regulatory work for hospitals. The position is accountable for the accreditation regulatory program, which includes identifying compliance gaps with state hospital licensing and accreditation standards, communicating high-risk issues to leadership, and ensuring staff are aware of rules pertaining to regulatory compliance. This is an experienced role for a professional who can be immediately effective on-site.

Key Responsibilities

• Lead regulatory survey readiness program planning to support the organization's mission, vision, and values.
• Conduct tracers, internal audits, and rounding activities to identify vulnerabilities and validate compliance with accreditation and regulatory standards.
• Proactively address accreditation and regulatory compliance issues, working with various departments to correct them before external review.
• Support post-survey activities, including the creation and monitoring of corrective action plans.
• Provide on-site accreditation survey support and assist in managing the Survey Command Center during surveys.
• Develop and implement regulatory education and core educational materials for leaders and caregivers.
• Serve as a liaison between assigned accreditation and regulatory bodies and the hospital.
• Act as a consultative resource for questions related to accreditation, Conditions of Participation (CoP), and state regulations.
• Participate on teams charged with regulatory improvement work as needed.

Required Qualifications

Education: An Associate Degree is required, with an RN or other clinical background. A Bachelor's Degree in a health-related field or equivalent knowledge and skills obtained through a combination of education, training, and experience is also required.

Experience: A minimum of five years of experience is required in a healthcare discipline, regulatory affairs, patient care, quality, or risk management. Experience with regulatory and compliance work, especially related to CMS Conditions of Participation, is essential. Previous experience supporting either Joint Commission or DNV (Det Norske Veritas) survey readiness is required.

Preferred Qualifications

• Knowledge of state, federal, and accreditation requirements, including CMS Conditions of Participation for acute care and critical access hospitals.
• Familiarity with accreditation standards and other regulatory areas such as the FDA and OSHA.

Everforth Apex offers a range of supplemental benefits, including medical, dental, vision, life, disability, and other insurance plans that offer an optional layer of financial protection. We offer an ESPP (employee stock purchase program) and a 401K program which allows you to contribute typically within 30 days of starting, with a company match after 12 months of tenure. Everforth Apex also offers a HSA (Health Savings Account on the HDHP plan), a SupportLinc Employee Assistance Program (EAP) with up to 8 free counseling sessions, a corporate discount savings program and other discounts. In terms of professional development, Everforth Apex hosts an on-demand training program, provides access to certification prep and a library of technical and leadership courses/books/seminars once you have 6+ months of tenure, and certification discounts and other perks to associations that include CompTIA and IIBA. Everforth Apex has a dedicated customer service team for our Consultants that can address questions around benefits and other resources, as well as a certified Career Coach.

Everforth Apex Systems is an equal opportunity employer. We do not discriminate or allow discrimination on the basis of race, color, religion, creed, sex (including pregnancy, childbirth, breastfeeding, or related medical conditions), age, sexual orientation, gender identity, national origin, ancestry, citizenship, genetic information, registered domestic partner status, marital status, disability, status as a crime victim, protected veteran status, political affiliation, union membership, or any other characteristic protected by law. Everforth Apex will consider qualified applicants with criminal histories in a manner consistent with the requirements of applicable law.