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 advance technology. Capital Health is a five-time Magnet-Recognized health system for nursing excellence and is comprised of 2 hospitals. Capital Health Medical Group is made up of more than 250 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 minimum pay 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).
Minimum Pay:
$94,556.80
Position Overview
JOB TITLE:Manager Regulatory Affairs

MINIMUM REQUIREMENTS

Education: Master of Science in Nursing or a related field.
Experience: Two or more years working in the area of regulatory affairs is preferred. Experience working with project management and/or supporting teams to improve acute care hospital /ambulatory care structures and processes is needed. Knowledge of performance improvement concepts is an important part of this role. Experience with LeapFrog survey activities is preferred.
Other Credentials: Registered Nurse - NJ, Registered Nurse - PA
Knowledge and Skills: Knowledge of DNV, The Joint Commission, ISO-9001, CMS, and Department of Health( NJ & PA ) standards. Ability to access and search standards to assist clinical and non-clinical teams in meeting goals and maintaining compliance. Knowledge of quality and performance improvement tools and techniques.
Special Training: Must have proficiency in the use of Word, Excel, and PowerPoint. Must be proficient in the development and use of tracking tools. Familiarity with the DNV and TJC secure extranet sites is preferred.
Mental, Behavioral and Emotional Abilities: Must have the ability to manage multiple projects and support multiple teams simultaneously. Must exercise discretion and independent judgment to achieve CH goals and objectives. Must have excellent written and oral communication skills.
Usual Work Day: Exempt Hours
Reporting Relationships
Does this position formally supervise employees? No
If set to YES, then this position has the authority (delegated) to hire, terminate, discipline, promote or effectively recommend such to manager.

• Manages organizational and/or department activities for regulatory surveys by external agencies such as the Department of Health ( NJ & PA), The Joint Commission, DNV, ISO-9001, CMS, OSHA, and others.
• Works collaboratively with Department Heads at CH to assure success in the achievement of accreditations, certifications, and re-certifications.
• Ensure preparation and ongoing readiness related to regulatory standards compliance. Works with teams within Capital Health to achieve compliance.
• Maintains up-to-date knowledge of regulatory requirements and manages process changes within CH to ensure compliance. Makes recommendations to enhance regulatory readiness.
• Manages the development of comprehensive and accurate responses to regulatory reports, citations, non-conformities, and requirements for improvement. Works collaboratively with other department managers plan for and achieve timely responses.
• Manages the data collection and submission for external surveys such as Leapfrog. 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.
• Serves as a resource for teams seeking new certifications and accreditations. Manages the gap analysis process and facilitates the team in working toward their goals.
• Serves as a resource for all departments considering changes in processes. Provides standards to address various issues under consideration.
• Works collaboratively with other departments such as Corporate Compliance, Legal, Risk management, Quality and Patient Safety, and Patient Services to achieve Capital Health goals.
• Plans for and manages on-site surveys (both announced and unannounced). Assures smooth operations during the visits. Collaborates with resources necessary to meet survey objectives.
• Serves as a resource for the Internal Audit Program at Capital Health. Works along-side other department managers and leaders to teach the process and reinforce the structures for the audit process.