Regulatory Accreditation Specialist

Hunterdon Health; Flemington (NJ); On-site; USD 98,000 - 122,000; Full time

Job summary

HHS Hunterdon Healthcare System Inc. is seeking an Accreditation and Regulatory Specialist to lead regulatory compliance and accreditation initiatives across the health system. The role requires directing departments to meet licensure and accreditation standards and coordinating readiness activities.

You will chair the Regulatory Readiness Committee, design compliance strategies, and train managers on survey processes, ensuring ongoing readiness for Joint Commission and other authorities.

Qualifications

• Bachelor's degree in nursing or healthcare field.
• Minimum 3 years of current experience in TJC hospital accreditation and compliance.
• Preferred: NJ RN License, CPHQ, CJCP.

Responsibilities

• Design and implement a systematic approach to raise awareness of regulatory and accrediting requirements.
• Ensure compliance with federal and state standards, including Joint Commission readiness.
• Chairs Regulatory Readiness Committee.
• Coordinate site visits, follow-up reports and compliance activities.
• Develop action plans from focused standards assessments.
• Monitor and implement activities to maintain accreditation and regulatory compliance.
• Train management staff on accreditation and survey activities.

Skills

project management

facilitation

leadership

process improvement

communication

team dynamics

problem solving

data visualization

Education

Bachelor's degree in Nursing or healthcare

Job description

Quality Improvement

HHS Hunterdon Healthcare System Inc., 2100 Wescott Drive, Flemington, NJ

Full-time

M-F, day shift, Day shift

Hiring Range: $97,731.66 - $122,164.58 Annually

Req # 80056

Position Summary

The Accreditation and Regulatory Specialist serves as the expert resource on regulatory/ accreditation and licensure standards and expectations for compliance. Provides direction to hospital departments to achieve and maintain accreditation and licensure.

Primary Position Responsibilities

• Design and implement a systematic approach to ensure a high level of awareness of regulatory and accrediting agency requirements throughout the healthcare system
• Ensures compliance with federal, state regulatory standards and licensing requirements, including Joint Commission readiness
• Chairs Regulatory Readiness Committee
• Coordinates site visits, follow-up reports, compliance activities
• Conducts focused standards assessment and action plans related to such.
• Assesses, monitors, and implements, as appropriate, activities and educational opportunities to maintain compliance with accreditation and/or regulatory standards
• Trains current and new management staff on their role in accreditation and survey activities

Qualifications

Minimum Education: Bachelor's Degree in Nursing or a healthcare related field

Preferred: None

Minimum Years of Experience (Amount, Type and Variation): A minimum of 3 years of current experience in TJC hospital accreditation and compliance to include regulatory survey coordination experience

Preferred: Active NJ RN License, Certified Professional in Healthcare Quality, (CPHQ), Certified Joint Commission Professional, (CJCP)

Knowledge, Skills and/or Abilities:

• Experience in project management, group facilitation, and leadership group presentations
• Knowledge and experience in process improvement methodologies
• Excellent verbal/written communication, interpersonal, and relationship-building skills
• Must possess a solid understanding of team dynamics
• Self-directed, highly motivated with superb problem-solving abilities
• Advanced computer skills to maintain databases, spreadsheets and develop reporting tools/graphs/control charts

• Benefit offerings vary based on status and may include but not be limited to medical, dental, vision, family forming, paid time off, tuition reimbursement, and retirement savings.

The hiring range listed is the potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement. When determining an applicant’s hourly rate and/or base salary, several factors may be considered as applicable (e.g., years of relevant experience, education, internal equity, and specialty).

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