Accreditation Regulatory Risk Management Specialist

Position: Accreditation Regulatory and Risk Management Specialist (Brockton)

Department: Brockton

Schedule: Full Time

ESSENTIAL RESPONSIBILITIES / DUTIES:

Accreditation/ Regulatory Responsibilities

• Serves as the organizational expert for The Joint Commission (TJC) Department of Public Health (DPH) Department of Mental Health (DMH) Centres for Medicare and Medicaid Services (CMS) standards regulations and conditions of participation.
• Responsible for the interpretation and communication of regulatory and licensing requirements throughout the organization.
• Provides education and consultation to administrative and clinical leadership staff and faculty throughout BMC regarding the requirements of accreditation and regulatory organizations.
• Provides guidance and assistance to departments sections units and programs regarding improvements needed to ensure compliance with requirements of TJC DPH DMH and CMS.
• Facilitates development of tools policies and procedures and learning aids to promote compliance with standards.
• Provides timely communication regarding new and revised TJC CMS DPH DMH standards and interpretations to administrative and clinical leadership staff and faculty.
• Works closely and builds effective working relationships with accreditation and regulatory agencies i.e. The Joint Commission DPH DMH and CMS.
• Responsible for all aspects of the plan to ensure continual readiness with the clinical regulatory and accreditation requirements of the TJC DPH DMH and CMS.
• This includes but is not limited to: Development coordination and implementation of the continual readiness plan; Ongoing assessment of the continual readiness plan; identification of needed improvements; and preparation and implementation of plans to achieve needed improvements
• Organizational department section unit and program assessments and identification of risk
• Plan and scheduling readiness mock surveys
• All ongoing communication with regulatory agencies regarding survey and readiness activities
• Development of remedial action plans
• Responding to agency requests for revision and corrective action plans
• Responsible for communication of the continuous readiness plan to leadership and key groups throughout BMC. Responsible for ensuring preparation of reports assessing institutional department section program and unit compliance with accreditation and regulatory requirements. Ensure that administrative and clinical leadership are continuously aware of BMC readiness for TJC DPH DMH and CMS surveys including description of specific issues that need improvement. Leads a coordinated response to unannounced external accrediting or regulatory agency visits such as TJC DPH DMH or CMS. Serves as a member on committees as deemed appropriate.

Risk Management Responsibilities