Regulatory Readiness Coordinator

Regulatory Readiness Coordinator

The Department of Public Health at Tewksbury Hospital is looking for a Regulatory Readiness Coordinator (Registered Nurse V). In this role, you will lead hospital-wide initiatives that support continuous readiness for accreditation and regulatory surveys, including The Joint Commission, the Centers for Medicare & Medicaid Services (CMS), the Massachusetts Department of Public Health (DPH), and other oversight agencies. Working closely with clinical and administrative leaders, you will help strengthen quality improvement efforts, foster a culture of compliance, and promote safe, patient-centered care across the organization. This is a great opportunity for an experienced nursing professional who enjoys driving organizational improvement, collaborating with multidisciplinary teams, and serving as a trusted expert in healthcare quality and regulatory standards. You will have the opportunity to influence hospital-wide practices through education, performance improvement initiatives, readiness planning, and strategic leadership. This is a 40 hour per week position on the first shift. The schedule is Monday - Friday, 7am-3:30pm. The days off are Saturday and Sunday.

Duties and Responsibilities:

• 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.

Required Qualifications:

• Knowledge of the principles and practices of healthcare.
• Knowledge of the terminology and standard abbreviations in healthcare.
• Knowledge of the methods used in the preparation of charts, graphs and tables.
• Knowledge of standard clinical policies, procedures, methods and techniques.
• Knowledge of interviewing techniques.
• Knowledge of problem-solving techniques.
• Ability to understand, explain and apply the laws, rules and regulations governing agency operations.
• Ability to 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.

Preferred Qualifications:

• Demonstrated experience leading regulatory readiness, accreditation, or healthcare compliance initiatives.
• Strong knowledge of The Joint Commission, CMS Conditions of Participation, and applicable state and federal healthcare regulations.
• Experience developing and implementing quality improvement and patient safety programs.
• Proven ability to lead multidisciplinary teams and influence organizational change without direct supervisory authority.
• Experience conducting regulatory tracers, mock surveys, and readiness assessments.
• Familiarity with performance improvement methodologies such as LEAN, Six Sigma, Root Cause Analysis (RCA), Failure Mode and Effects Analysis (FMEA), or similar approaches.
• Exceptional written and verbal communication skills, with the ability to effectively educate and engage clinical and non-clinical staff.
• Strong analytical, organizational, and problem-solving skills with exceptional attention to detail.
• Experience developing and delivering education and training related to quality, patient safety, or regulatory compliance.
• Ability to build collaborative relationships across all levels of a healthcare organization while fostering a culture of continuous improvement and accountability.

About the Department of Public Health:

The mission of the Massachusetts Department of Public Health (DPH) is to prevent illness, injury, and premature death, to assure access to high quality public health and health care services, and to promote wellness and health equity for all people in the Commonwealth. We envision a Commonwealth in which all people enjoy optimal health. Massachusetts ranks among the healthiest states according to comparative analyses, but we face numerous challenges, including chronic and infectious disease, substance abuse, violence, preventable hospitalizations, and health disparities. DPH coordinates programs and policies to address specific diseases and conditions and offer services to address the needs of vulnerable populations. We also develop, implement, promote, and enforce regulations and policies to assure that the conditions under which people live are most conducive to health and enable people to make healthy choices for themselves and their families. We license health professionals, healthcare facilities and a variety of businesses that impact public health. We operate the state laboratory and four public health hospitals. We monitor health status and manage vital records including births, marriages and deaths. We educate people about public health issues and work closely with local boards of health and community partners to identify and solve public health problems.

Pre-Hire Process:

A criminal background check will be completed on the recommended candidate as required by the regulations set forth by the Executive Office of Health and Human Services prior to the candidate being hired. For more information, please visit . Education, licensure and certifications will be verified in accordance with the Human Resources Division's Hiring Guidelines. Education and license/certification information provided by the selected candidate(s) is subject to the Massachusetts Public Records Law and may be published on the Commonwealth's website.

For questions concerning this requisition, please contact Employment and Staffing Customer Service at View phone number on click.appcast.io. For technical questions accessing MassCareers, please contact Mass HR at View phone number on click.appcast.io. ADA Reasonable Accommodation: If you require a reasonable accommodation with the application/interview process, please contact us at: EOHHS Candidate ADA Requests

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