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Director of Regulatory (BSN Required)

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Location: Teaneck, NJ, United States
Date Posted:



Holy Name Medical Center is a leading healthcare facility dedicated to providing compassionate, high-quality care to our community. We are committed to fostering a dynamic and inclusive work environment for our employees.

A Brief Overview
This position is responsible for ensuring regulatory compliance and excellent quality for the organization. This position is responsible to provide content expertise on regulatory standards as it pertains to the hospital setting, the coordination of survey readiness activities and working closely with clinical and non-clinical leaders. In collaboration with the organization's department leaders, promotes a de-centralized approach to quality and survey readiness by supporting development of the infrastructure, promoting accountability for knowledge and interpretation of standards by all hospital departments.

What you will do

  • Collaborate with the CMO and senior level management to continue to refine our regulatory strategy
  • Monitor newly published Joint Commission, CMS and FDA guidelines and international guidance documents
  • Manage processes to detect, document and execute opportunities for quality improvement
  • Communicate quality system status at the company through management reviews, quality audits, post-market surveillance and other quality management processes
  • Ensure optimal utilization of resources and compliance with the operating standards of various health care governing and accrediting bodies
  • Identify areas for quality improvement related and collaborate with organizational leadership to develop and implement improvement programs and teams as needed
  • Ensures programs and projects are evidence based and collaborative
  • Oversees the preparation, development of certification applications, interim reports and data tables in collaboration with Data Science
  • Provides direction to department and facility leadership in planning of a systematic, organization-wide approach to continuous regulatory readiness
  • Coordinates the planning and execution of The Joint Commission (TJC) Annual Period Performance Review (PPR) and any mid-cycle consultant survey activities
  • Conducts tracer activities, facilitates assessments, develops, implements, and evaluates corrective action plans
  • Stays informed about emerging trends, regulations, best practices in the software and healthcare industries and share regulatory updates, insights, and recommendations with internal stakeholders
  • Works collaboratively with the Patient Safety Officer, Risk Manager, Quality Officer, Safety Officer, and other department heads to facilitate improvement teams to achieve system quality and patient safety goals
  • Performs other duties as assigned

Education Qualifications

  • Bachelor's Degree in nursing Required
  • Master's Degree Preferred

Experience Qualifications

  • Minimum of five years working in an acute care setting with progressive areas of responsibility in positions in performance improvement, quality, or management experience in regulatory compliance, TJC, and CMS/Magnet survey processes. Required
  • Excellent working knowledge of Joint Commission standards and CMS Conditions of Participation is required.

Knowledge, Skills, and Abilities

  • Ability to provide leadership and promote collaboration, including the proven ability to work effectively with staff, faculty, senior management, and other team members.
  • Ability to provide proactive, flexible, and customer service focused advice; work effectively with others; and demonstrate ethics and integrity in a professional manner, sensitivity to confidentiality.

Licenses and Certifications

  • CCRP - Certified Clinical Research Professional Upon Hire Preferred

Holy Name Medical Center is a comprehensive, 361-bed hospital offering leading-edge medical practice and technology administered in an environment rooted in a tradition of compassion and respect for every patient. Holy Name provides high quality health care across a continuum that encompasses education, prevention, early intervention, treatment options, rehabilitation and wellness maintenance. The Medical Center offers a robust roster of primary care and specialty physicians, and its Sister Claire Tynan School of Nursing provides academically competitive registered nurse and licensed practical nurse education programs. Ranked among the top hospitals in New Jersey and the nation for patient care, clinical performance, consumer value and workplace excellence, Holy Name has been recognized by NJBIZ's as one of the "Best Places to Work in New Jersey" every year since 2006 - the only hospital to have earned this honor. The Medical Center is fully accredited by The Joint Commission, is Magnet-recognized by the American Nurses Credentialing Center, consistently earns Hospital Safety Grade A scores from Leapfrog Group, and is a national model for culturally sensitive care. Holy Name is a mission-driven facility whose quality standards and philosophy are rooted in the principles of its founders, the Sisters of St. Joseph of Peace. Those principles are exercised daily by the Medical Center's dedicated and talented team of physicians, nurses, allied health employees, and a wide variety of non-clinical administrative and operational staff members. Holy Name Medical Center is an Equal Opportunity Employer.