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058111 Requisition #
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The incumbent is the organizational expert with focused responsibilities in leading Regulatory Compliance including the Joint Commission (TJC), Centers for Medicare and Medicaid (CMS), Ohio Department of Health (ODH), and other local, state and federal agencies, including the TJC disease specific certifications. The incumbent functions as a critical resource to evaluate policies and standards established by outside regulatory agencies, provides direct input into their interpretation, and determines the organization’s compliance


A knowledge base that includes understanding the regulatory process at the local, regional, state and national level, including working knowledge of the Joint Commission/CMS Standards and the survey process. The incumbent must demonstrate expertise in:

o Communication across disciplines.

o Managing group dynamics.

o Performance improvement processes.

o Must be able to articulate the value and vision for “survey readiness: in a manner that portrays its positive aspects to patient care.

o Must be willing to serve as a change agent within the organization.

The Regulatory Compliance and Accreditation Specialist Coordinator assists the organizations in complying with their overall regulatory and accreditation requirements and/or those programs that facilitate maintaining regulatory compliance. The incumbent interfaces with all employees either directly or indirectly through the management structure comprised of physicians, administrators, department heads, and front line management, along with direct providers, by assisting them in determining effective and innovative solutions.

The hospital-based incumbent’s oversight consists of the hospital main campus and off site hospital based locations; and may include serving as an assist or back-up to other hospitals and their corresponding off-sites. The program-based incumbent’s oversight consists any or all hospitals and their corresponding off-sites, as pertaining to the assigned program.

Both the hospital-based and the program-based incumbent provides regulatory compliance oversight in various forums including: Medical Staff, management forums, patient care delivery forums, forums that support clinical care delivery and other physician-championed forums. The incumbent is responsible for coordinating organizational efforts that will engage employees in the continuous readiness survey “mode.” This is accomplished through formal committee structure, serving as a resource to individuals working with regulatory updates, interpretation with changes in rules and standards, along with timely communication.

The incumbent is an organizational expert, who evaluates regulations and standards established by outside agencies, providing direct input into their interpretation and determining the organizations’ compliance. The incumbent will serve as a designated administrative liaison for the management team to all regulatory and accreditation-driven committees in place at the facility and/or for those assigned organization-wide programs that directly impact organizational regulatory compliance.

The Regulatory and Accreditation Specialist Coordinator serves as a resource to the organization to assist in the evaluation of policies, procedures, audits and related processes, interim life safety measures, against standards and conditions, to determine compliance. In addition, this position assists in the clarification, modification and the development of these policies, standards and programs, and provides an advanced level of support to process improvement activities that lead to compliance.

Other Duties & Functions:

The location-based incumbent assumes the lead facilitator role in coordination, adherence to, and as the point person/ facilitator for the Joint Commission Accreditation and Disease Certification Programs. This includes bi-annual on-site surveys, along with Intra-cycle reviews. The scope includes the application process, updates, and monitoring of survey results with compliance.

Minimum Level of Education Required: Bachelor's degree

Additional requirements:Type of degree: BSN

Area of study or major: Nursing

Preferred educational qualifications: Advanced Degree preferred


Licensure/Certification/Registration:  Valid Ohio RN license


Minimum Level of Experience Required: 5 - 7 years of job related experience

Other experience requirements: Clinical experience in healthcare required

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