Regulatory Readiness Coordinator - RN V

Schedule: Monday - Friday 8:00AM-4:30PM

• Responsible for the development, coordination, and implementation of the continual readiness plan for Joint Commission Accreditation and CMS Condition of Participation.
• Serves as the organizational expert for regulations surveyed through the Joint Commission accreditation standards, CMS condition of participation for hospitals. Supports and monitors compliance of policies and procedures with standards and regulatory requirements.
• Responsible for the interpretation and communication of the regulatory requirements and standards including the applicable hospital licensure requirements. This may include requirements from non-clinical agencies such as Occupational Safety and Health Administration (OSHA).
• Serves as the organizational contact for the Joint Commission account representative and maintains effective working relationship.
• Provides direction and guidance during the Triennial Joint Commission survey as the survey Command Center Leader.
• Oversees the development of remedial action plans and evidence of standards compliance for internal findings as well as any Joint Commission survey findings. Ensures the findings are reported to appropriate committees.
• Chairs the hospital Regulatory Readiness Committee and ensures committee charter, membership and functional responsibilities are supporting the ongoing readiness activities such as standards self-assessment, periodic performance review, tracer activities and action plans for any areas of non-compliance.
• Provides oversight and reports on the progress for ongoing assessment of the continual readiness plan, identification of needed improvements, and preparation and implementation of plans to achieve needed improvements. Ensures the effective use of regulatory readiness software to monitor progress.
• Develops and/or facilitates the development of tools, procedures and learning tools pertaining to regulatory readiness. Provides education and training for accreditation requirements in collaboration with Education Leader (RNVI).
• Leads or participates in hospital performance improvement including root cause analysis, causal analysis, proactive risk assessments including Failure Mode Effects analysis, regulatory readiness activities, and performance improvement methodologies including LEAN/Six Sigma.

• Knowledge of the principles and practices of healthcare.
• Comprehends the terminology and standard abbreviations in healthcare.
• Experience in the methods used in the preparation of charts, graphs, and tables.
• Knowledge of standard clinical policies, procedures, methods, and techniques.
• Experience in interviewing techniques.
• Knowledge of problem-solving techniques.
• Ability to understand, explain and apply the laws, rules and regulations governing agency operations.
• Can give written and oral instructions in a precise, and understandable manner.
• Ability to write clearly and concisely.
• Ability to gather information through observing and questioning individuals, and by examining records and documents.
• Can establish and maintain harmonious working relationships with others.
• Ability to participate in multi-disciplinary health care team.
• Ability to maintain confidentiality of patient information.
• Skill to analyze and determine the applicability of medical data, to draw conclusions and make appropriate recommendations.
• Knowledge of training methods and techniques.
• Ability to plan and conduct training or instruction in nursing.

• Knowledge of the laws, rules, regulations, policies, procedures, specifications, standards, and guidelines governing agency and assigned unit activities.
• Ability to explain the laws, rules, regulations, policies, procedures, specifications, standards, and guidelines.
• Knowledge of the methods used to evaluate nursing practices.
• Knowledge of the principles and practices of healthcare administration.
• Familiar of state laws, procedures, and guidelines.

About the Lemuel Shattuck Hospital:

Pre-Hire Process:

• Education toward such a degree will be prorated on the basis of the proportion of the requirements actually completed.

• Recent graduates from an approved school of nursing must have applied for the first available registered nurse examination.

Comprehensive Benefits

When you embark on a career with the Commonwealth, you are offered an outstanding suite of employee benefits that add to the overall value of your compensation package. We take pride in providing a work experience that supports you, your loved ones, and your future.

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Title 101 CMR 23.00 (“Regulation”) requires certain agency staff to have received the COVID-19 vaccination and Influenza vaccination, or have taken required mitigation measures, to prevent viral infection and transmission in State Hospitals and State Congregate Care Facilities. The Regulation applies to this position. Successful candidates will be required to acknowledge and attest to your vaccination status for both COVID-19 and Influenza.