Director, Regional Regulatory - Clinical Regulatory Compliance - Full Time

Up to a $25,000 sign on bonus. 

The pay range for this role is $40.25-62.59.

Position Summary: 

Provides leadership to the organization relative to Clinical Regulatory Compliance program which assures the implementation and oversight of clinical requirements developed by Center for Medicare and Medicaid (CMS), the Department of Health (DOH), and The Joint Commission (TJC). The primary purpose of the Clinical Regulatory Compliance Program is to ensure that the hospital's policies and practices comply with the requirements of external organizations that regulate or accredit the hospital, and to monitor the organization's compliance with its own policies. This function is distinct from the compliance program that operates under the authority of the Compliance Officer. Provide leadership to include the assessment, development and evaluations of programs related to staff education for all staff throughout the facility.

Education, License & Cert: 

Bachelor’s degree in Nursing.  A Master’s degree, in Education or Nursing, is preferred. Licensed Registered Nurse in the appropriate state.

Experience: 

Minimum of five years acute hospital experience. Prior experience in leadership/management desired. Demonstrated effective communications, critical thinking/problem solving skills required.

Essential Functions: 

1. Assumes leadership responsibilities for the program including: 

a. Goal setting, developing monitoring tools, status reporting 

b. Organizing department 

c. Budget planning and management 

d. Monitoring the work of others outside the department 

e. Utilizes data for decision making and strategic planning 

2. Prepares reports to regulatory agencies on a timely basis 

a. Submits required reports to external agencies 

b. Develops corrective action plans as required 

c. Monitors and reports on the implementation of corrective action plans 

3. Responsible for assuring that the organization complies with new clinical requirements announced by the Joint Commission, CMS, or the DOH

a. Ensure that the hospital's leadership is aware of new requirements 

b. Ensure that plans are developed and implemented to meet these requirements 

c. Ensure that newly implemented processes are integrated into ongoing management and operational activities 

d. Ensures that effectiveness of regulatory action plans or new processes are monitored to evaluate compliance 

e. Keeps hospital leaders and administration (including the Board) informed of regulatory findings and action plan progress via formal and/or informal reports on a regular basis 

4. Demonstrates ability to be a person of influence 

a. Builds trust 

b. Provides leadership for implementing changes/performance improvement efforts, even though operational area may not directly report to this position 

c. Creates a work environment that enhances employee, patient and physician satisfaction 

d. Sets performance expectations/goals and maintains high standards of performance 

e. Collaborates with organizational line management to assure full compliance 

5. Provides a consulting/facilitation role in the organization for performance improvement activities and processes. 

a. Facilitates committees, teams and workgroups 

b. Supports medical staff initiatives 

c. Assists in project development and management 

d. Assists in operationalizing electronic health record changes (i.e. orders, documentation fields/screens) that are consistent with clinical regulations and hospital policies.

Other Duties:

1. It is understood that this description is not intended to be all‐inclusive.  Other duties may be assigned as necessary. 

2. Takes Administrator An Call assignment 

3. Travel is required

Joining the Guthrie team allows you to become a part of a tradition of excellence in health care. In all areas and at all levels of Guthrie, you’ll find staff members who have committed themselves to serving the community.

The Guthrie Clinic is an Equal Opportunity Employer.

The Guthrie Clinic is a non-profit, integrated, practicing physician-led organization in the Twin Tiers of New York and Pennsylvania. Our multi-specialty group practice of more than 500 physicians and 302 advanced practice providers offers 47 specialties through a regional office network providing primary and specialty care in 22 communities. Guthrie Medical Education Programs include General Surgery, Internal Medicine, Emergency Medicine, Family Medicine, Anesthesiology and Orthopedic Surgery Residency, as well as Cardiovascular, Gastroenterology and Pulmonary Critical Care Fellowship programs. Guthrie is also a clinical campus for the Geisinger Commonwealth School of Medicine.