This position provides programmatic regulatory management, direction and advisory across MHealth Fairview system to achieve and sustain clinical and operational compliance to regulating bodies such as the Joint Commission (TJC), Centers for Medicare and Medicaid (CMS), Minnesota Department of Health (MDH), and other identified entities. This position will serve as a system program manager for regulatory and accreditation for Fairview Health Services with oversight and support responsibility of regulatory activities at designated sites or service lines ensuring that business practices and activities follow applicable local, federal, and state laws, regulations, policies, etc. The individual is an expert contributor responsible for assigned system accreditation activities ranging from program design, projects, initiatives, evaluation, readiness, monitoring, and implementation. Role will be responsible for providing regulatory survey support for site(s), leading identified system regulatory improvement project(s) and continuous evaluation of program activities.
Additional role will include managing the day to day activities for Fairview Health Systems regulatory response infrastructure. This position will collaborate with other internal partners to ensure adherence to the organizations regulatory response policies, procedures, and timelines, as well as manage our regulatory activity database and analyze trends for risks, vulnerabilities, and improvement.
Prepare and implement system regulatory standards, strategies and accreditation readiness activities.
Manage accreditation/certification submissions or applications, post survey reporting, monitoring, and compliance assessment
Design and provide system regulatory education, management of regulatory requirements and distribution, and participation in continuous quality improvement system efforts to achieve sustained compliance.
Management and transparency of regulatory data to assigned site(s) and system leaders for enhanced visibility of regulatory activities, compliance, and impact of efforts.
Management of regulatory and accreditation management systems (i.e. TJC connect, AMP, ECM Plus, etc.)
Provide site and/or service line regulatory survey support , lead identified regulatory improvement projects and implement continuous evaluation of program effectiveness
Implement regulatory strategy, processes for regulatory readiness, compliance, and response that is aligned with system regulatory efforts.
Assist in deploying systems to manage regulatory activities, submissions, concerns, and surveys.
Programmatic partner to designated site(s) and/or service line(s) across Fairview Health Systems, as well as a backup support to other sites.
Identify and integrate new and changing regulatory requirements into the system relating to JC, CMS, MDH and other accreditation bodies.
Assist site teams on Regulatory Agency or Accreditation Organization surveys to include TJC, MDH- CMS, but not limited to these entities. This includes on-site support but not limited to coordination of documents, surveyor interviews, communication to leaders of survey progress, and assists in development and monitoring of action plans.
Serve as a system subject matter expert and advisor for regulatory standards and requirements to sites and/or service lines.
Manage effective implementation and evaluation of Fairviews regulatory response infrastructure.
Develop and manage system regulatory survey activity scorecard and dashboard
Provide support and involvement in other applicable regulatory activities, as determined.
Bachelors degree in a healthcare field or other related field.
3-5 years experience working with accreditation and regulatory compliance and/or investigations in a healthcare setting including experience working with physicians, leaders and staff with accountability for improvements and outcomes.
Experience and accountability working in large, integrated health care delivery systems or other related healthcare organizations.
Clinical setting experience and/or background
Masters degree in related field or a law degree
CMS or other regulatory compliance and investigation work; legal experience.
Any Regulatory certification (e.g. CCMSCP, CPHQ, other)
Additional Preferred Experience:
A broad base of knowledge in the following areas:
TJC standards and processes for all health care delivery system components (behavioral, hospital, ambulatory, home care, home medical equipment, behavioral)
Department of Health & Human Services (DHS) regulations
Conditions of Participation (CoP/Centers for Medicare & Medicaid Services CMS) regulations
Performance Improvement theory and processes
Strong computer skills (Microsoft Word, Excel, PowerPoint)
Laws, regulations and standards that impact Mhealth Fairview and each of its entities
Together with the University of Minnesota and University of Minnesota Physicians we have created M Health Fairview. M Health Fairview is the newly expanded collaboration among the University of Minnesota, University of Minnesota Physicians, and Fairview Health Services. The healthcare system combines the best of academic and community medicine — expanding access to world-class, breakthrough care through our 10 hospitals and 60 clinics.
Fairview Health Services (fairview.org) is an award-winning, nonprofit health system providing exceptional care across the full spectrum of health care services. Fairview is one of the most comprehensive and geographically accessible systems in the state, with 10 hospitals—including an academic medical center and long-term care hospital—serving the greater Twin Cities metro area.
Its broad continuum also includes 60 primary care clinics, specialty clinics, senior living communities, retail and specialty pharmacies, pharmacy benefit management services, rehabilitation centers, counseling and home health care services, medical transportation, an integrated provider netwo...rk and health insurer PreferredOne. In partnership with the University of Minnesota, Fairview’s 32,000 employees and 2,400 affiliated providers embrace innovation to drive a healthier future through healing, discovery and education.