**This position is 100% on-site in Richmond, VA**
**Candidates for this position must have RN Licensure in Virginia or eligible or compact state required**
The Regulatory Affairs Manager is responsible for managing compliance with accreditation, federal regulatory and licensing standards related to the delivery of safe and effective patient care throughout the Health System.
The Regulatory Affairs Manager designs and implements a systematic approach to ensure high level of awareness and compliance with accrediting and federal agency requirements throughout the health system including ramifications of failures in compliance. The Regulatory Affairs Manager serves as an expert resource for compliance expectations related to all accreditation, federal regulatory and licensing standards including but not limited to The Joint Commission, Center for Medicare and Medicaid Services, FDA, OSHA, Virginia Department of Health and Virginia Department of Mental Health. The role oversees the Health System Hospital Policy and Procedure Committee to ensure compliance and works closely and collaboratively with the medical staff, nursing, clinical and non-clinical personnel and leadership to implement improvement strategies to assure continual readiness.
Licensure, Certification, or Registration Requirements for Hire:
Current RN Licensure in Virginia or eligible or compact state required
Certified Professional in Healthcare Quality (CPHQ) or Certified Professional in Healthcare Risk (CPHRM) Or
Certified Joint Commission Professional (CJCP) preferred
Licensure, Certification, or Registration Requirements for continued employment:
Current RN Virginia license required
Current CPHRM or CPHQ or CJCP certification preferred
Experience REQUIRED:
Minimum of five (5) years of progressive leadership/management experience
Previous experience with developing and implementing CMS-2567 Corrective Action Plans, Joint Commission Evidence of Standard Compliance and new programs.
Previous experience with managing unannounced accreditation and regulatory surveys
Previous experience with compliance requirements for hospital accreditation and disease specific certification
Previous work experience managing, coaching and providing feedback to employees
Experience PREFERRED
Seven (7) years of progressive leadership/management experience
Previous experience in an academic medical center environment
Education/training REQUIRED:
Master's Degree in Health Care Administration, Business Administration, Nursing or other healthcare related field from an accredited program, OR Bachelor's Degree in Health Care Administration, Business Administration, Nursing, or healthcare related field from an accredited program AND seven (7) years of progressive leadership/management experience.
Education/training PREFERRED: N/A
Independent action(s) required:
Management of daily operations within the Regulatory Affairs Department.
Advice and guidance are sought from Director on an as needed situational basis and when there is a major impact on activity.
Actions that are taken without prior approval include daily operational functions and leadership of staff.
With guidance from the Director, advice and guidance are sought for termination of employees, handling employee grievances, review of annual unit goals and budget, approval on unit guidelines and procedures and review of staff annual performance evaluations.
Supervisory responsibilities (if applicable):
Has full authority and accountability for actions and decisions within the scope of the job description and hospital policies and procedures.
Manages the Regulatory Affairs staff.
Additional position requirements:
While the job is generally Monday - Friday, 8 a.m. to 5 p.m., work may be necessary on evenings and weekends depending on the project and any on-call duties.
Age Specific groups served: All
Physical Requirements (includes use of assistance devices as appropriate):
Physical Lifting 20-50 lbs.
Activities: Walking (distance), Climbing (steps, ladder, other)
Mental/Sensory: Strong recall, Reasoning, Problem solving, Hearing, Speak clearly, Write legibly, Reading, Logical thinking
Emotional: Fast pace environment, Able to handle multiple priorities, Frequent and intense customer interactions, Able to adapt to frequent change EEO Employer/Disabled/Protected Veteran/41 CFR 60-1.4.
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Virginia Commonwealth University Health Systems
Nov 20, 2024