Compensation Disclaimer

Compensation for this role is based on a number of factors, including but not limited to experience, education, and other business and organizational considerations.

Department: Regulatory

FTE: 1.00
Full Time
Shift: Days

Position Summary:
This leadership position plans, directs, manages and oversees assigned programs and activities for accreditation, regulatory, and licensing standards related to the delivery of safe and effective patient care. Responsible for UNMH regulatory readiness and overseeing regulatory and accreditation visits ensuring the appropriate staff and leadership are involved and that the process is facilitated at all times during the visit. Investigate and respond to regulatory complaints; investigate both proposed and new patient care regulations and laws and make initial recommendations for ensuring compliance. Work directly with leadership and physicians to develop required action plans for deficiencies. Develop and maintain an ongoing mechanism for monitoring action plans with deficiencies. Coordinate assigned activities with other divisions, departments and outside agencies; ensure work quality and adherence to established policies and procedures. Ensure adherence to Hospitals, Health System and departmental policies and procedures. No patient care assignment.

Detailed responsibilities:
* SUPERVISION - Develop efficient organizational structure. Supervise employees and select, terminate, train, educate, correct deficiencies, perform appraisals, issue discipline, counsel, schedule work assignments; encourage staff teamwork and growth initiatives
* OPERATIONS - Assume management responsibilities for business services and activities within assigned area
* QUALITY - Ensure adherence to established policies, procedures and regulations related to accreditation standards and regulatory requirements
* POLICIES - Manage and participate in the development and implementation of goals, objectives, policies and procedures for assigned area(s); monitor and evaluate the efficiency and effectiveness of service delivery methods and procedures
* REPORTS - Prepare reports as required; oversee and ensure compliance with quality reporting for all regulatory and licensing bodies
* COMMITTEES AND MEETINGS - Participate in hospital/medical staff meetings and committees as required
* BUDGET - Assist in the preparation and administration of the annual budget; monitor fiscal status and reports; investigate and resolve variances
* ANALYSIS - Carry out risk analysis for regulatory compliance, discover areas of potential regulatory risk and vulnerability, and create and implement solutions to eliminate the potential risk
* MANAGEMENT - Manage and direct regulatory training and educational programs
* REPORTING - Prepare report for leadership on regulatory activity and action plans
* STRATEGY- Develop strategies to ensure that all entities covered by the UNM Hospital operator license maintain continual survey readiness
* LIAISON - Serve as a liaison between regulatory bodies and hospital operations
* LIAISON - Develop and maintain professional relationships with federal, state and local regulatory agencies
* MONITOR - Monitor regulatory affairs and the effect changes will have on hospital practice or operations; Assure appropriate organizational response to changes

Qualifications

Education:
Essential:
* Bachelor's Degree
Nonessential:
* Master's Degree
Education specialization:
Essential:
* Related Discipline
Nonessential:
* Related Discipline

Experience:
Essential:
2 years directly related experience

Nonessential:
No preferred experience

Credentials:

Nonessential:
* RN in NM or as allowed by reciprocal agreement by NM
* CPHQ or CJCP w/in 2 years

Physical Conditions:
Sedentary Work: Exerting up to 10 pounds of force occasionally (Occasionally: activity or condition exists up to 1/3 of the time) and/or a negligible amount of force frequently (Frequently: activity or condition exists from 1/3 to 2/3 of the time) to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.

Working conditions:
Essential:
* No or min hazard, physical risk, office environment
* Subject to an annual contract and performance appraisal