GENERAL SUMMARY:



Under limited direction, plans, organizes and maintains a process to ensure organizational compliance with regulatory standards and continuous survey readiness. Serves as an internal consultant for the interpretation of standards and functional measurement of compliance. Develops performance improvement plans with management/staff on an as needed basis. Interprets new regulations for education purposes and implementation efforts.



PRINCIPAL DUTIES AND RESPONSIBILITIES:



· In collaboration with corporate and business unit leadership: Provides direction and oversight to regulations/accreditation compliance including but not limited to: TJC, DNV, State and Federal agencies (CMS) for hospital/system.

· Develops and monitors the org. infrastructure necessary to assure ongoing compliance with standards/regulations.

· Functions as a consultant, resource, ...