Manager Regulatory Compliance
CHRISTUS Trinity Mother Frances
Legal and Compliance
CHRISTUS Mother Frances Hospital Tyler
800 East Dawson Street
Tyler, TX 75701
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Provides administrative management and oversight of Regulatory and Accreditation Compliance within CHRISTUS Mother Frances Hospital – Tyler and associated clinics.
Ensures compliance with all hospital-based Joint Commission and CMS standards. Provides regulatory and accreditation support to departments and committees as assigned. Serves as educator for regulatory and accreditation tools and standards.
Ensures accountability- Holding self and others accountable to meet commitments.
Communicates effectively- Developing and delivering multi-mode communications that
convey a clear understanding of the unique needs of different audiences.
Manages conflict- Handling conflict situations effectively, with a minimum of noise.
Drives results- Consistently achieving results, even under tough circumstances.
Business insight- Applying knowledge of business and the marketplace to advance the
Builds effective teams- Building strong-identity teams that apply their diverse skills and
perspectives to achieve common goals.
Develops talent - Developing people to meet both their career goals and the organization’s
·Develops, implements, and monitors policies, readiness activities and procedures to ensure compliance with applicable laws, regulations, and accreditation standards, which may include CMS Conditions of Participation, Joint Commission Standards, Joint Commission Advanced Disease Specific Certifications, NCQA, HIPAA, OSHA, etc.
·Consults with Hospital Leadership to identify areas of non-compliance and works with department management to develop action plans to address.
·Develops written policies and procedures that ensure continued standards compliance, coordinates the development of education and training programs relating to regulatory and accreditation issues, and ensures continued compliance through the utilization of and management of various tracer methodologies.
·Leads and/or participates in various committees as directed.
·Graduate of a State Board School of Nursing, BSN preferred.
- Minimum 2 years in Quality Management or Joint Commission survey readiness. Will consider a candidate with strong inpatient clinical background in lieu of quality experience.
- Experience leading others, preferred
- Experience with computer-based tools such as E-mail (Outlook), Excel, Word, Access.
C. Licenses, Registrations, or Certifications
·Current Texas RN License
·Certified Professional in Healthcare Quality or Certified Joint Commission Professional (CJCP) preferred