Career Center

Director, Regulatory Compliance

It's more than a career, it's a calling.

MO-SSM Health St. Mary's Hospital - Jefferson City

Worker Type: Regular

Job Highlights:

Named 150 Top Places to Work in Healthcare 2023 - Becker's Healthcare

Named One of America's Greatest Workplaces for Diversity 2023 - Newsweek

Named One of America's Greatest Workplaces for Women 2023, 2024 - Newsweek

SSM Health is a Catholic, not-for-profit health system serving the comprehensive health needs of communities across the Midwest through a robust and fully integrated health care delivery system. The organization’s 40,000 team members and more than 12,800 providers are committed to providing exceptional health care services and revealing God’s healing presence to everyone they serve.
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With care delivery sites in Illinois, Missouri, Oklahoma and Wisconsin, SSM Health includes 23 hospitals, more than 300 physician offices and other outpatient and virtual care services, 13 post-acute facilities, comprehensive home care and hospice services, a pharmacy benefit company, a health insurance company and an accountable care organization. It is one of the largest employers in every community it serves.

To request additional information, confidentially submit your interest, or nominate a fellow colleague, please contact:

Jon Dirksen

Executive Talent Acquisition

jon.dirksen@ssmhealth.com

Job Summary:

Achieves regulatory compliance and strategic goals of the assigned region. Leads and facilitates teams to ensure ongoing monitoring of key metrics and processes that lead to compliance with The Joint Commission (TJC) and state requirements and organization's regulatory goals. Shares best practices with staff and between teams.

Job Responsibilities and Requirements:

Primary Responsibilities

• Ensures that best practices and initiatives are reviewed and implemented, regulatory noncompliance is reviewed to identify opportunities for improvements, and action plans are completed and implemented. Maintains working knowledge of regulatory compliance councils, and other related meetings, to assess and ensure essential requirements are met and best practices are identified and shared with teams. Leads identified regulatory compliance improvement initiatives, providing an assessment of opportunities for improvement, and identifying strategies to achieve strategic goals. Completes and maintains a strong knowledge of regulatory compliance principles, tools, and techniques. Leads or participates meetings as assigned.
• Manages administrative functions by coordinating the development of plans, policies, budget, and procedures related to the Joint Commission compliance, departmental goals, and ensures coordination/integration across the organization. Collaborates with department directors and administrative council in planning initiatives to support compliance with goals and standards; participates in meetings to share applicable information. Ensures ongoing compliance and survey preparedness with respect to hospital licensing requirements, Centers for Medicare & Medicaid Services (CMS) Conditions of Participation and accreditation by The Joint Commission and other applicable regulatory, certification, and accrediting bodies/agencies.
• Guarantees the well-being of staff by developing, mentoring, educating and coaching staff to maximize personal and professional performance in compliance with risk, quality, patient experience, patient safety, and regulatory requirements as well as staff's individual goals and leadership shaping. Promotes and maintains a safe work environment for staff. Manages departmental functions such as employee orientation, overseeing production and work assignments, and resolution of team-related issues.
• Coordinates accreditation education and consultative services regarding regulations, standards interpretation, and implementation. Ensures proper and detailed analysis of accreditation and regulatory risk issues related to The Joint Commission Standards and the corresponding CMS Conditions of Participation, state and federal regulations.
• Collaborates with leadership for positive accreditation and licensure outcomes by developing tools and procedures to assess compliance to standards. Serves as a subject matter expert to the leadership team, medical staff, department directors and others about the licensure and accreditation process and standards. Prepares the application for survey and coordinating site visits/inspections. Serves as the subject matter expert regarding applicable regulatory, licensing and accreditation bodies, their review processes and standards. Improves regulatory compliance through consistent application of regulatory standards, communicates and escalates issues in a timely fashion. Holds staff accountable for timely, accurate corrective plans of actions.
• Contributes to overall employee satisfaction by leading monthly and ad hoc staff meetings and working cohesively with team members. Provides best practices and suggestions for improvement to staff. Oversees effective human resource management, including adherence to human resource policies and procedures for assigned staff. Supervises assigned team members, including hiring, evaluation, scheduling, and ongoing coaching. Facilitates an environment that promotes team building and collaboration. Motivates, encourages, and empowers staff to achieve personal, team, departmental, and organization goals. Maintains flexibility in hours and work assignments to support the entities throughout the network. Provides backup to direct reports as required to meet essential department functions. Recognizes individual and team accomplishments.
• Contributes to the overall financial performance of the department through staffing that is consistent with budget goals, efficient department operations, and by following policies and procedures. Provides input to the annual budgeting process. Oversees review and assessment to ensure accurate reporting to CMS and minimize the financial impact on all entities.
• Maintains exceptional knowledge of the Joint Commission and CMS Conditions of Participation. Reviews corrective plans of action and measures of successes monthly or more frequently. Enforces compliance with monthly tracers and follow-up with noncompliance and completion as needed. Provides backup to team members to ensure thorough investigations and corrective plan of actions for Condition Level and Immediate Jeopardy Deficiencies.
• Ensures that staff have the resources needed to meet CMS Conditions of Participation and The Joint Commission (TJC) requirements. Supports Patient Safety and Quality as requested with Root Cause Analysis. Maintains thorough knowledge of writing Corrective Plans of Actions, Evidence of Standards Compliance (ESCs) following the required methodology to support CMS and TJC requirements.
• Performs other duties as assigned.

Education

• Bachelor's degree

Experience

• Five years' experience, with three years' in direct people management/leadership to include managing programs

Required Professional License and/or Certifications

• Certified Joint Commission Professional (CJCP) - Joint Commission Resources (JCR)

Department: 8754000033 Regulatory

Work Shift: Day Shift (United States of America)

Scheduled Weekly Hours: 40

SSM Health is an equal opportunity employer. SSM Health does not discriminate on the basis of race, color, religion, national origin, age, disability, sex, sexual orientation, gender identity, pregnancy, veteran status, or any other characteristic protected by applicable law. Click here to learn more.

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