WellStar Health Systems Executive Director Accreditation & Regulatory Standards in marietta, Georgia
At WellStar we all share common goals. That’s what makes us so successful – and such an integral part of our communities. We want the same things, for our organization, for our patients, and for our colleagues. As the largest not-for-profit healthcare system in Georgia, this means we pride ourselves on investing in the communities that we serve. We continue to provide innovative care models, focused on improving quality and access to healthcare.
The Executive Director of Regulatory Compliance reports to the AVP of Safety and Regulatory Compliance. The Executive Director serves as a system expert for regulatory accreditation to advance the organizations operational performance related to accreditation compliance. The Executive Director provides expertise and consultation on Joint Commission (TJC); Georgia Department of Human Resources (DHR); Center for Medicare and Medicaid Services (CMS); OSHA Standards, and other regulatory standards and requirements and related processes. This position is responsible for development and provision of strategies to support continuous survey readiness (CSR) activities, utilizing AMP software to improve safety, and regulatory compliance across the healthcare system. The Executive Director keeps System AVP of Safety and Regulatory Compliance and all other facility leaders informed of WellStar’s survey readiness status as well as new/revised regulatory requirements and the impact on the organization. He/she ensures routine self-assessment of compliance with various standards/regulations, development of action plans, review and revision of related policies and procedures and submission of Periodic Performance Reviews to the JC. The Executive Director supports the System during various survey review activities to prevent the utilization of outside survey consultants, i.e. JC survey, OSHA, State visits. Works closely with the Quality Directors at the facility sites to ensure timely submission by all of recommendations for improvement and deficiencies identified by outside agencies. The Executive Director oversees the System OSHA safety plan and assures education and training is completed as required by the OSHA regulations both for healthcare and the industry standards.
Master’s degree in a healthcare related field.
RN Licensure preferred. Certified Joint Commission Professional Certification required or within one year of position hiring
Certification within OSHA healthcare and industry preferred
5 years’ experience in coordinating regulatory agency survey activities including TJC, CMS, OSHA, DHR, and state reviews related to hospitals, post-acute care, hospice, home care, and OSHA industry
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Join us for outstanding benefits and development opportunities. We also offer state-of-the-art technology, professional support and advancement, and colleagues that rank amongst the best in the country. The WellStar culture of caring has also been nationally recognized three years in a row by Fortune Magazine as one of the “100 Best Companies to Work For”. Step up to your potential. Find out more and apply today.
WellStar is an equal opportunity/affirmative action employer. All applicants are considered without regard to race, color, religion, sex, age, national origin, disability, veteran status or any status which is protected by local, state or federal law.
Department Executive Director Accreditation & Regulatory Standards
Facility WellStar Shared Services