Manager, Regulatory Affairs

HMH HOSPITALS CORPORATION Hackensack Requisition # 2020-87721 ShiftDay StatusFull Time with Benefits Weekend WorkNo Weekends Required HolidaysNo Holidays Required On CallNo On-Call Required Shift Hours8:30am - 5pm Address30 Prospect Avenue, Hackensack, 07601

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How have you impacted someone's life today? At Hackensack Meridian Health our teams are focused on changing the lives of our patients by providing the highest level of care each and every day. From our hospitals, rehab centers and occupational health teams to our long-term care centers and at-home care capabilities, our complete spectrum of services will allow you to apply your skills in multiple settings while building your career, all within New Jersey's premier healthcare system.

The Manager, Regulatory Affairs is assigned the responsibility/accountability for coordination of the TJC (The Joint Commission) accreditation and Disease Specific Care certifications. Primary responsibility is to provide ongoing support, instruction, and leadership to meet and exceed all accreditation standards, and to ensure ongoing readiness for accreditation throughout all accredited programs. Works with the Dir, Regulatory Affairs to respond to and coordinates investigation by the Joint Commission, DOH and other external regulatory agencies. Serves as the Medical Center's expert resource on accreditation and certification and as the organizational liaison with Joint Commission.


A day in the life of Manager, Regulatory Affairs at Hackensack Meridian Health includes:

  • Facilitates/coordinates regulatory activities throughout all credited programs. Collaborates with staff, physicians, and administration to ensure successful regulatory surveys.
  • Supports leadership meetings related to survey readiness and provides regular readiness reports. With the Dir, Regulatory Affairs, functions as the Chair of the Joint Commission Steering Committee. 
  • With the Director, Regulatory Affairs, coordinates the system level regulatory readiness process.
  • With the Director, Regulatory Affairs, monitors and acts on system level readiness reports from enterprise wide readiness software. 
  • Assures survey readiness through the implementation of a continuous survey readiness program. Communicates regulatory activities with team members and staff.
  • Remains current with regulatory standards to assure on-going compliance. Demonstrates an understanding and knowledge of TJC accreditation and certification processes; DOH state licensure regulations and other regulatory agencies.
  • Coordinates and facilitates JCAHO activities related to constant survey readiness.
  • Participates in JCAHO accreditation process and surveys for the Medical Center via detailed preparation, engaging in mock survey activities and facilitating follow-up of corrections and recommendations. 
  • Monitors staff compliance to JCAHO standards.
  • Demonstrates knowledge of the continuous quality improvement and performance improvement process and has broad knowledge of patient safety issues.
  • Develops and implement entity wide training to maintain compliance with Joint Commission and other regulatory standards. 
  • Assures the development of organizational compliance review and monitoring activities. Conducts audits as required to ensure compliance. 
  • Makes recommendations and implements change to organizational processes based on findings of the compliance review.
  • Assesses practice and reviews content of policies and procedures to assure compliance with standards.
  • Lifts a minimum of 10 lbs., pushes and pulls a minimum of 20 lbs. and stands a minimum of 4 hours a day.
  • Adheres to the standards identified in the Medical Center's Organizational Competencies.


Education, Knowledge, Skills and Abilities Required:

  • Bachelor's degree. 
  • Minimum 6 years of audit or performance improvement experience in a hospital, consulting firm or practice management setting.
  • Clinical background and familiarity with hospital operations.
  • Proficiency with physician documentation and medical terminology.
  • Demonstrated competency with Joint Commission standards and familiarity with NJ State DOH and CMS regulations.
  • Computer proficiency and demonstrated presentation skills required.
  • Interacts with Senior Leadership and Governance, Management, Medical Staff, Medical Center Staff and the public.

If you feel that the above description speaks directly to your strengths and capabilities, then please apply today!

Our Network

As a courtesy to assist you in your job search, we would like to send your resume to other areas of our Hackensack Meridian Health network who may have current openings that fit your skills and experience.