Accreditation/Regulatory Specialist Hospital Services

Boys Town National Research Hospital; Omaha (NE); On-site; USD 60,000 - 80,000; Full time

Job summary

Boys Town National Research Hospital in Omaha, NE, is seeking an Accreditation/Regulatory Specialist to provide leadership and oversight of accreditation and regulatory compliance for hospital services. The ideal candidate will work collaboratively with hospital leadership to maintain readiness for regulatory reviews and ensure compliance with standards.

Key responsibilities include conducting training, developing action plans for compliance, and conducting audits while cultivating a culture of belonging and respect in the workplace.

Qualifications

• Minimum 2 years of experience in quality improvement, clinical outcomes management or standards/regulation activities in a hospital setting required.

Responsibilities

• Provide leadership and oversight of accreditation and regulatory compliance programs.
• Conduct training on Joint Commission/CMS regulatory topics.
• Develop action plans and educational programs to improve compliance.

Skills

Communication skills

Leadership

Team collaboration

Statistical analysis

Education

Current valid RN license or bachelor's degree in healthcare or related field

Job description

Business: Boys Town National Research Hospital

Job Summary

In a career as an Accreditation/Regulatory Specialist Hospital Services, you join us in providing life‑changing care to patients from across the region. In this role, you will provide leadership and oversight of accreditation and regulatory compliance programs for hospital services. Work collaboratively with Boys Town National Research Hospital leadership to build effective programs for the achievement of ongoing readiness for accrediting/regulatory reviews for the Surgery Center and the Inpatient Units.

Schedule: Full‑Time, 8:00 AM-4:30 PM Monday-Friday

Location: Downtown Clinic

Major Responsibilities & Duties

• Maintains expertise in current and proposed Joint Commission and CMS standards, OSHA, state and federal regulatory requirements.
• Completes medical record review documentation audits.
• Works collaboratively with the organization’s quality team and Patient Safey Officer to maintain ongoing readiness binders and required documentation for Joint Commission survey.
• Integrates the analysis and reporting of data and information into continual readiness and performance improvement activities and reports.
• Utilizes statistical tools and methods to communicate and measure results.
• Conducts training on Joint Commission/CMS regulatory topics.
• Provides periodic reports to leadership regarding compliance with required standards.
• Develops and leads mock surveys/tracer activities in the hospital setting; identifies and communicates positive and negative trends and findings.
• Coordinates the development of action plans and educational programs to improve compliance with problematic standards to achieve ongoing readiness.
• In collaboration with the nurse educator, assists with annual competencies and e‑learning course development and updates.
• In collaboration with the organization's quality team, assists with the development of plans, policies and procedures that guide, support, and ensure that all clinical services are provided in accordance with standards established through state and federal regulations and Joint Commission accreditation standards.
• Researches community best practices for hospital services.
• Excellent communication, presentation and written skills.
• Ability to maintain harmonious working relationships with all departments.

Required Qualifications

• Current valid RN license or bachelor's degree in healthcare or related field required.
• Minimum 2 years of experience in quality improvement, clinical outcomes management or standards/regulation activities in a hospital setting required.

Care and respect for others is more than a commitment at Boys Town – it is the foundation of who we are and what we do. At Boys Town, we cultivate a culture of belonging for all employees that respects their individual strengths, views, and experiences. We believe that our differences enable us to be a better team – one that makes better decisions, drives innovation, and delivers better business results. This advertisement describes the general nature of work to be performed and does not include an exhaustive list of all duties, skills, or abilities required. Boys Town is an equal employment opportunity employer and participates in the E-Verify program. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity and/or expression, national origin, age, disability, or veteran status. To request a disability‑related accommodation in the application process, contact us at 1‑877‑639‑6003.