Director, Regulatory Affairs

Director Of Regulatory Affairs

Jackson Health System is a nationally and internationally recognized academic medical system offering world-class care to any person who walks through our doors. For more than 100 years, Jackson has evolved into one of the world's top medical providers for all levels of care, no matter if it's for a routine patient visit or for a lifesaving procedure. With more than 2,000 licensed beds, we are also proud of our role as the primary teaching hospital for the University of Miami Miller School of Medicine.

Here, the best people come together to deliver Jackson's mission for our diverse communities. Our employees are committed to providing the best CARE by demonstrating compassion, accountability, respect, and expertise in everything we do.

The Director Of Regulatory Affairs is a member of the leadership team who is responsible for the organization-wide oversight and resolution of regulatory and hospital licensure matters including process changes, new requirements, and compliance with all regulatory standards required for patient safety and quality of care and services and promotion of continuous survey readiness. The incumbent may directly interface with regulatory authorities on specific projects or products to ensure that JHS is adhering to all applicable government regulations and successfully manage multiple projects simultaneously while adapting to changing project priorities.

Duties and responsibilities include :

• Managing confidential information within the department and related involved employees, patients, visitors, and / or physicians.
• Responsible for the organization-wide oversight and resolution of regulatory and hospital licensure matters including survey preparation, process changes, new requirements, and compliance with all regulatory standards required for patient safety and quality of care and services.
• Providing organizational support to the Corporate Director of Regulatory Affairs to ensure effective communication and oversight of the organizational responses to unannounced regulatory visits and inspections and timely completion and submission of licenses, applications, certification, and accreditation documentation.
• Assisting facility in preparations for surveys (i.e., State, The Joint Commission, Center for Medicare and Medicaid Services, AHCA), conducting quality and patient safety surveys, and ensuring continuous readiness for State and Federal surveys.
• Leading or organizing tracers / mock surveys with the interdisciplinary team to assess, drive, and maintain continuous survey readiness, communicate findings and concerns, and follow up on action plans across the organization.
• Participating in organization-wide committees and administrative meetings of various departments and campuses as necessary to address regulatory standards or concerns and relate information to various disciplines as appropriate.
• Collaborating with Risk Management in the facilitation of root cause analysis (RCA), failure mode and effects analysis (FMEA), and monitoring of action plan implementation.
• Serving as a liaison with various regulatory agencies and entities for matters on program / hospital / system wide accreditation and licensure and / or certifications.
• Collaborating with the leadership at different levels throughout the organization in establishing and prioritizing goals and actions, process improvements on deficiencies and significant findings relevant to patient safety and quality of care.
• Coordinating the development of data collection tools and review of data. Leading, coordinating, investigating, and responding to complaint and / or quality concerns received via Federal and State agencies and related entities.
• Collaborating with Risk Management in relation to incidents that may result in regulatory visits and / or sentinel event reporting.
• Maintaining regulatory and other hospital survey readiness and compliance data collection systems with oversight of audit tools and results for continuous compliance and developing statistical and qualitative reports on a monthly / quarterly basis to critically oversee the organization's adherence to compliance indicators and target goals.
• Promoting the performance improvement, patient satisfaction, and employee satisfaction as goals of the organization.
• Serving as a resource to the organization for interpretation of standards of regulatory and accrediting agencies and providing support in the communication and integration towards the mission and vision of the organization to all staff.
• Performing other related duties as assigned. Making recommendations for improvement and monitoring status of resolution regarding identified issues, as appropriate.
• Maintaining strict confidentiality of all information discovered in the review process.
• Interpreting and evaluating clinical data, identifying variations in care / deviation from standards based on specific criteria determined by TJC and CMS.
• Developing TJC preparation timelines and following up to successfully meet survey goals.
• Maintaining, utilizing, and communicating current knowledge of regulatory agency requirements and standards.
• Role modeling behaviors of service excellence and CARE values (Compassion, Accountability, Respect and Expertise).
• The leader understands and adheres to JHS compliance standards as they appear in the Code of Conduct, Compliance Policies, and all other JHS Policies and Procedures and supports the commitment of JHS in adhering to federal, state, and local laws, rules, and regulations governing ethical business practices for health care providers by demonstrating knowledge of procedures for protecting and maintaining security, confidentiality, and integrity of employee, patient, family, and organization information.
• The leader further understands that JHS is committed to its role in preventing health care fraud and abuse and complying with applicable state and federal laws related to health care fraud and abuse.
• This commitment is supported and enabled through an anonymous hotline which serves as one of several mechanisms for reporting suspected fraud, waste, and / or abuse, as well as other compliance-related issues. The leader to report through any of the reporting mechanisms (e.g., anonymous hotline, supervisor, Compliance Officer) any suspected health care fraud, waste, and / or abuse as well as other compliance-related issues.
• Performing all other related job duties as assigned.

Generally requires 7 to 10 years of related experience. Management experience is required. Bachelor's degree in a related field is required. Master's degree is strongly preferred. Valid Florida RN license or other type of healthcare practitioner license is required.

Jackson Health System is an equal opportunity employer and makes employment decisions without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran status, disability status, age, or any other status protected by law.