Job Summary:

Reporting to the Vice President of Quality and Safety, the Regulatory Coordinator supports all aspects of compliance with The Joint Commission Accreditation Standards, Centers for Medicare and Medicaid Services Conditions of Participation, Massachusetts Department of Public Health regulations, and other applicable external regulatory, accreditation, and certification requirements. This role independently collaborates and coordinates accreditation and regulatory readiness activities with Risk Management, Compliance, and Quality and Safety to support ongoing organizational compliance and performance improvement.

Job Responsibilities:

1. Regulatory Compliance

· Facilitate development of system-wide initiatives to strengthen regulatory compliance and accreditation readiness.

· Support complex and sensitive issues requiring adherence to federal, state, and accrediting body requirements.

· Collaborate across Baystate Health departments to implement and sustain standardized accreditation, survey readiness, and regulatory processes.

· Participate in and support ongoing hospital compliance with The Joint Commission, CMS Conditions of Participation, and Massachusetts Department of Public Health regulations.

· Assess regulatory compliance, identify gaps in standards, and facilitate development, implementation, and monitoring of corrective action plans.

· Participate in Environmental Rounds to identify, communicate, and support resolution of safety risks and regulatory noncompliance.

· Support survey preparation, participate in on-site surveys, and lead post-survey follow-up activities, including corrective action planning with hospital leadership.

· Navigate and manage The Joint Commission Connect portal, including application submissions, regulatory activity review, invoice management, and corrective action plan submissions.

· Serve as a subject matter expert on regulatory and accreditation standards, providing guidance during compliance assessments and readiness activities.

2. Audit and Data Tracking

· Develop, utilize, and maintain audit tools, tracers, and regulatory reports.

· Maintain data collection and analysis of compliance activities; analyze trends to inform performance improvement and regulatory readiness efforts.

· Collaborate with key stakeholders to design tracers and performance metrics.

· Lead monthly regulatory readiness meetings to monitor and report compliance status.

3. Staff Education

· Educate leaders and staff on regulatory requirements and standards interpretation through presentations, training sessions, and development of educational materials, including Microsoft PowerPoint.

Skills/Competencies:

o Strong written and verbal communication, active listening, and interpersonal skills.

o Critical thinking skills to assess compliance gaps and support corrective action planning.

o High attention to detail with strong documentation, auditing, and tracking capabilities.

o Ability to manage multiple priorities independently and meet regulatory deadlines.

o Discretion in handling sensitive, confidential, and regulatory related information.

o Collaborative, team-oriented approach with the ability to work across departments.

Required Education/Experience:

• Bachelor of Science

Preferred Education/Experience:

• Minimum 3 years in healthcare-related or regulatory-related roles.

Education:

Bachelor of Science (Required)

Certifications:

Compensation

Note: The compensation range(s) in the table below represent the base salaries for all positions at a given grade across the health system. Typically, a new hire can expect a starting salary somewhere in the lower part of the range. Actual salaries may vary by position and will be determined based on the candidate's relevant experience. No employee will be paid below the minimum of the range. Pay ranges are listed as hourly for non-exempt employees and based on assumed full time commitment for exempt employees.

Minimum – Midpoint – Maximum

$83,054.00 – $95,472.00 – $112,923.00

Equal Employment Opportunity Employer