Job Description​

Manage, oversee and coordinate all activities related to maintaining an ongoing state of regulatory compliance through proactive risk assessments and mitigation efforts. Requires 1 to 3 years' work experience in the regulatory, accreditation or compliance field. In the critical access region, 1 to 3 years' work experience is preferred.

• Create a culture of continuous regulatory readiness through continual proactive measures. Educate all levels of staff, including managers, directors and senior leaders to regulatory requirements including regulations and standards in development.

• Conduct regular assessments through audits (formal and informal), mock tracers and mock surveys.

• Respond to actual or potential noncompliance identified via these assessments by ensuring that appropriate corrective measures have been taken and that they have successfully eliminated the risk or deficiency. Oversee ongoing monitoring to ensure sustained regulatory compliance.

• Manage all aspects of investigations, inspections and surveys conducted by regulatory and accrediting agencies: prepare for and facilitate visits, ensuring appropriate oversight of the regulators/surveyors. Respond to deficiencies by ensuring that appropriate corrective measures have been taken and that they have successfully eliminated the deficiency. Oversee ongoing monitoring to ensure sustained regulatory compliance.

• Serves as the hospital's liaison with regulatory and accrediting agencies, including but not limited to: The Joint Commission, The Department of Health, OSHA, and the FDA. In this role, represent the hospital during surveys from regulatory agencies.

• Serve as the Chair for the TJC Steering Committee.  Serves as a member of the Quality and Patient Safety Council, Environment of Care, Policy Committees and other committees as deemed appropriate.

Job Requirements

Applicable Experience:

Job Details

The best place to get care. The best place to give care. Saint Luke’s 12,000 employees strive toward that vision every day. Our employees are proud to work for the only faith-based, nonprofit, locally owned health system in Kansas City. Joining Saint Luke’s means joining a team of exceptional professionals who strive for excellence in patient care. Do the best work of your career within a highly diverse and inclusive workspace where all voices matter.

Join the Kansas City region's premiere provider of health services. Equal Opportunity Employer.

Effective November 1st, 2021, full COVID-19 vaccination is a condition of employment for all Saint Luke’s Health System employees unless a medical or religious exemption is approved.