Employment Type:Full timeShift:Day ShiftDescription:Position PurposeAssists with monitoring of Joint Commission (JC) and other applicable federal, state and local regulatory and/or accrediting agencies. Coordinates, establishes and maintains an integrated approach for evaluations and maintains compliance with all external regulatory agencies. These responsibilities include all acute care network and behavioral heath network hospital programs. Provides ongoing auditing of established policies and processes that impact hospital operations.What you will do
Review of regulatory data as it relates to JC standards and other regulatory bodies
Assist the Manager of Regulatory Compliance with preparation and coordination of all JC survey processes
Assist with all State license visits including to the Department of Public Health (DPH) and the Department of Mental Health (DMH)
Assist the Director of Weldon Rehab with the C.A.R.F. tri-annual survey visits and accreditation
Assure that all mandatory monitoring is collected, analyzed and updated
Monitor changes in all regulatory standards and review for compliance
Conduct “Mock Tracers” for educational and assessment purposes
Collaborate with all department mangers and Department of Education to maintain a current state of “survey readiness”
Analyzes data for trends and areas of noncompliance
Maintain a performance improvement function that exceeds JC and other external regulatory agencies requirements
Compile department regulatory compliance profiles and assures accuracy of all data included in the reports
Oversee implementation of policies, procedures, objectives and regulatory improvement activities
Minimum Qualifications
BSN required; current licensure required as a Registered Nurse in the Commonwealth of Massachusetts
Three years of acute care experience and one-year recent experience in regulatory compliance, including knowledge of the Comprehensive Accreditation Manual for Hospitals (JC)
One-year recent experience with the Commonwealth of Massachusetts regulations (CMR), and the Department of Mental Health
Knowledge of regulatory compliance standard interpretations including self-assessment tools and processes required.
Position Highlights and Benefits
Full time 40hr salaried Mon-Fri days
Excellent benefits starting day 1
Ministry/Facility InformationMercy Medical Center has established itself as one of the leading providers of health care services in Western Massachusetts. Mercy Medical Center is a 182-bed acute care hospital in Springfield. Other facilities include Mercy's Rehabilitation Hospital, a comprehensive hospital-based rehabilitation center on the campus of Mercy Medical Center and Brightside for Families and Children, an outpatient service offering counseling and family support programs.Our Commitment to Diversity and InclusionTrinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by law.Our Commitment to Diversity and InclusionTrinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity.EOE including disability/veteran
