Capital Health is the region's leader in providing progressive, quality patient care with significant investments in our exceptional physicians, nurses and staff, as well as advanced technology. Capital Health is a dynamic health care resource accredited by the DNV that includes two hospitals, an outpatient center, satellite ED, and an expansive network of primary and specialty care. Capital Health Medical Group is made up of more than 600 physicians and other providers who offer primary and specialty care, as well as hospital-based services, to patients throughout the region.

Capital Health recognizes that attracting the best talent is key to our strategy and success as an organization. As a result, we aim for flexibility in structuring competitive compensation offers to ensure we can attract the best candidates.

The listed pay range or pay rate reflects compensation for a full-time equivalent (1.0 FTE) position. Actual compensation may differ depending on assigned hours and position status (e.g., part-time).

Pay Range:

$94,556.80 - $124,176.00

Scheduled Weekly Hours:

40

Position Overview

Reporting to the Manager of Regulatory Affairs, coordinates organization-wide as well as program-specific activities related to the regulatory process and the respective governing bodies, including NJ Department of Health, Centers for Medicare and Medicaid Services (CMS), DNV and others. Coordinates activities related to continuous survey readiness, including tracer activity. Acts as a resource for Capital Health staff regarding regulations and requirements. Assists teams in planning for disease-specific or program-specific certifications and accreditations. Assists with coordinating activities related to on-site and other surveys. Assists teams in the development of action plans and measurement of these actions to measure compliance, and participates in the submission of Novi Surveys to the Department of Health. Works closely with policy owners and users to support the implementation, development, and maintenance of PolicyStat. Participates in the Policy, Procedure, and Forms Committee to ensure that all policies and forms are reviewed, and published once finalized.

Education: Bachelor of Science of Nursing. Master of Science in Nursing, Education, or a related field preferred.

Experience: Two years of experience in regulatory affairs. Experience working with project management and/or supporting teams to improve clinical quality and regulatory non-conformances.

Other Credentials: Registered Nurse - NJ, Registered Nurse - PA

Knowledge and Skills: Knowledge of DNV, CMS, and NJ and PA Department of Health standards. Ability to access and search standards to assist clinical teams in meeting goals and maintaining compliance. Knowledge of quality and performance improvement tools and techniques. Demonstrates knowledge of data collection, interpretation, and presentation. Must have the ability to work on multiple projects and support various tasks simultaneously, exercising discretion and independent judgment to achieve CH goals and objectives. Must have excellent written and verbal communication skills.

Special Training: Must have proficiency in the use of Word, Excel, and PowerPoint. Must be proficient in the development and use of tracking tools.

Mental, Behavioral and Emotional Abilities: Must have the ability to work on multiple projects and support multiple tasks simultaneously, exercising discretion and independent judgment to achieve CH goals and objectives. Must have excellent written and verbal communication skills.

Usual Work Day: Exempt Hours

• Coordinates organizational and/or departmental activities for regulatory surveys by external agencies such as the NJ Department of Health, the PA Department of Health, and DNV. Works collaboratively with department heads to assure success in the achievement of accreditations, certifications, and recertification’s.

• Participates in the submission of Novi Surveys to the Department of Health.

• Ensures preparation and ongoing readiness related to regulatory standards compliance.

• Maintains up-to-date knowledge of regulatory requirements and coordinates process changes within Capital Health to ensure compliance.

• Develops comprehensive and accurate responses to regulatory reports, citations, and requirements for improvement. Works collaboratively with other hospital leaders to ensure timely responses.

• Coordinates the data collection and submission for the Regulatory Affairs Committee. Assures validated data submission and documentation. Prepares gap analyses and recommends detailed plans for improvement.

• Works with various departments to develop tracking tools and other mechanisms to measure regulatory compliance.

• Coordinates DNV Tracer activity with follow-up reports.

• Provides consultation to policy owners and users on implementation, revision, and maintenance of policies.

• Supports the Policy, Procedure, and Forms Committee to ensure policies and forms are disseminated for review and posted to Capital Link when finalized.

• Performs other duties as assigned.

PHYSICAL DEMANDS AND WORK ENVIRONMENT:

• Frequent physical demands include: Sitting , Wrist position deviation , Pinching/fine motor activities , Keyboard use/repetitive motion

• Occasional physical demands include: Standing , Walking , Climbing (e.g., stairs or ladders) , Carry objects , Push/Pull , Twisting , Bending , Reaching forward , Reaching overhead , Squat/kneel/crawl

• Continuous physical demands include: Talk or Hear

• Lifting Floor to Waist 20 lbs. Lifting Waist Level and Above 10 lbs.

• Sensory Requirements include: Accurate Near Vision, Accurate Far Vision, Accurate Color Discrimination, Accurate Hearing

• Anticipated Occupational Exposure Risks Include the following: Bloodborne Pathogens , Airborne Communicable Disease

This position is eligible for the following benefits:

• Medical Plan

• Prescription drug coverage & In-House Employee Pharmacy

• Dental Plan

• Vision Plan

• Flexible Spending Account (FSA)

- Healthcare FSA

- Dependent Care FSA

• Retirement Savings and Investment Plan

• Basic Group Term Life and Accidental Death & Dismemberment (AD&D) Insurance

• Supplemental Group Term Life & Accidental Death & Dismemberment Insurance

• Disability Benefits – Long Term Disability (LTD)

• Disability Benefits – Short Term Disability (STD)

• Employee Assistance Program

• Commuter Transit

• Commuter Parking

• Supplemental Life Insurance

- Voluntary Life Spouse

- Voluntary Life Employee

- Voluntary Life Child

• Voluntary Legal Services

• Voluntary Accident, Critical Illness and Hospital Indemnity Insurance

• Voluntary Identity Theft Insurance

• Voluntary Pet Insurance

• Paid Time-Off Program

The pay range listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the future. When determining base salary and/or rate, several factors may be considered including, but not limited to location, years of relevant experience, education, credentials, negotiated contracts, budget, market data, and internal equity. Bonus and/or incentive eligibility are determined by role and level.

The salary applies specifically to the position being advertised and does not include potential bonuses, incentive compensation, differential pay or other forms of compensation, compensation allowance, or benefits health or welfare. Actual total compensation may vary based on factors such as experience, skills, qualifications, and other relevant criteria.

Reporting to the Manager of Regulatory Affairs, coordinates organization-wide as well as program-specific activities related to the regulatory process and the respective governing bodies, including NJ Department of Health, Centers for Medicare and Medicaid Services (CMS), DNV and others. Coordinates activities related to continuous survey readiness, including tracer activity. Acts as a resource for Capital Health staff regarding regulations and requirements. Assists teams in planning for disease-specific or program-specific certifications and accreditations. Assists with coordinating activities related to on-site and other surveys. Assists teams in the development of action plans and measurement of these actions to measure compliance, and participates in the submission of Novi Surveys to the Department of Health. Works closely with policy owners and users to support the implementation, development, and maintenance of Policy. Stat. Participates in the Policy, Procedure, and Forms Committee to ensure that all policies and forms are reviewed, and published once finalized. MINIMUM REQUIREMENTS:Education: Bachelor of Science of Nursing. Master of Science in Nursing, Education, or a related field preferred. Experience: Two years of experience in regulatory affairs. Experience working with project management and/or supporting teams to improve clinical quality and regulatory non-conformances. Other Credentials: Registered Nurse - NJ, Registered Nurse - PA - Knowledge and Skills: Knowledge of DNV, CMS, and NJ and PA Department of Health standards. Ability to access and search standards to assist clinical teams in meeting goals and maintaining compliance. Knowledge of quality and performance improvement tools and techniques. Demonstrates knowledge of data collection, interpretation, and presentation. Must have the ability to work on multiple projects and support various tasks simultaneously, exercising discretion and independent judgment to achieve CH goals and objectives. Must have excellent written and verbal communication skills. Special Training: Must have proficiency in the use of Word, Excel, and PowerPoint. Must be proficient in the development and use of tracking tools. Mental, Behavioral and Emotional Abilities: Must have the ability to work on multiple projects and support multiple tasks simultaneously, exercising discretion and independent judgment to achieve CH goals and objectives. Must have excellent written and verbal communication skills. Usual Work Day: Exempt Hours ESSENTIAL FUNCTIONS:Coordinates organizational and/or departmental activities for regulatory surveys by external agencies such as the NJ Department of Health, the PA Department of Health, and DNV. Works collaboratively with department heads to assure success in the achievement of accreditations, certifications, and recertification’s. Participates in the submission of Novi Surveys to the Department of Health. Ensures preparation and ongoing readiness related to regulatory standards compliance. Maintains up-to-date knowledge of regulatory requirements and coordinates process changes within Capital Health to ensure compliance. Develops comprehensive and accurate responses to regulatory reports, citations, and requirements for improvement. Works collaboratively with other hospital leaders to ensure timely responses. Coordinates the data collection and submission for the Regulatory Affairs Committee. Assures validated data submission and documentation. Prepares gap analyses and recommends detailed plans for improvement. Works with various departments to develop tracking tools and other mechanisms to measure regulatory compliance. Coordinates DNV Tracer activity with follow-up reports. Provides consultation to policy owners and users on implementation, revision, and maintenance of policies. Supports the Policy, Procedure, and Forms Committee to ensure policies and forms are disseminated for review and posted to Capital Link when finalized. Performs other duties as assigned.

search terms: Regulatory Affairs+Regulatory