Regulatory Consultant

Position Summary This position plans, coordinates, implements and evaluates facility(s)/entity(ies) and regulatory programs for preparedness and accreditation/certification/licensure requirements. The incumbent serves as a subject matter expert to leadership, staff, and system teams/work groups related to regulatory requirements to ensure standards are met. Core Functions Responsible for implementation of regulatory requirements using standardized regulatory processes in one or more facilities/entities. Prepares facilities/entities for surveys by evaluating standardized infection prevention/control and Environment of Care (EOC)/Life Safety (LSC) regulatory processes. Reviews, evaluates and assists in the development and implementation of facility/entity policies, procedures and guidelines related to regulatory compliance. Provides recommendations on all facility matters related to compliance with Joint Commission, CMS, national/state/local regulations and professional standards. Conducts observations, tracers, building tours, document reviews and interviews to ascertain facility compliance with standards, rules and regulations. Documents findings and provides facility with reports and recommendations for change; updates the Joint Commission application. Provides direction and education to functional team leads on the Periodic Performance Review, standardized metrics and action plans for resolution of identified non‑compliance. Supports development and monitors completion of facility plans of correction and assists department managers in developing corrective actions. Responds to notices of surveyor arrival and directs survey management activities; initiates post‑survey activities to ensure readiness. Schedules and participates in unannounced corporate surveys system‑wide; works with leadership to prepare for survey readiness. Identifies and coordinates compliance activities of specialist content experts such as infection control and EOC/LS specialists. Provides support and guidance during life safety, environment of care, emergency management and infection control events; evaluates events to ensure standards and regulatory requirements are not compromised. Reports to senior leadership on compliance trends, recommends improvement strategies, presents data and deficiencies identified during internal observations/tracers, and updates on system compliance trends. Serves as subject matter expert on internal and external regulatory standards, provides education on regulatory changes, and guides leaders and staff. Serves on assigned committees, chairs or co‑chairs as appointed, schedules and maintains regulatory meetings, and updates committees on current and future plans. Maintains regulatory expertise through independent study, workshops, professional publications, networks, and professional societies. Performs multi‑facility responsibility and system‑wide regulatory activities, functioning autonomously and educating leaders and staff system‑wide on regulatory issues. Minimum Qualifications Bachelor’s degree in nursing or another health‑care related field. Five years of relevant experience in a hospital setting plus three years regulatory experience. Strong knowledge of regulations and standards within the focus area. Ability to manage programs, projects and databases. Demonstrated excellence in interpersonal and written communication skills. Flexible, service‑oriented philosophy; ability to respond to needs of multiple constituencies. Demonstrated leadership and facilitation of interdisciplinary teams. Ability to perform complex statistical analysis and provide advanced problem‑solving skills. Preferred Qualifications Experience in a surveyor role and in process improvement, regulatory/accreditation programs, data management and analysis, graphic development and presentations. For clinical assignments, current clinical license or certification preferred. For life safety and environment of care assignments: Certified Safety Professional (CSP) or Certified Health Care Safety Professional (CHCSP) or similar certification preferred. Additional related education and/or experience preferred. EEO Statement: Banner Health is an equal opportunity employer and encourages applications from all qualified individuals. We support a drug‑free work environment. #J-18808-Ljbffr