Chief of Regulatory Readiness and Medical Affairs

The Essentia Health Chief of Regulatory Readiness and Medical Affairs working in close collaboration with the Quality Administrator, Chief Quality Patient and Safety Officer and others is responsible for development, management, coordination, integration and evaluation of EH’s regulatory and accreditation activities. The EH Chief of Regulatory Readiness and Medical Affairs works closely with Physician and Professional Staff Services and Hospital Medical Staff leaders to ensure compliance with standards and conditions, including Medical Staff Bylaws, Rules, Regulations, and Medical Staff Policy requirements. The EH Chief of Regulatory Readiness and Medical Affairs is responsible to provide strategic and operational direction to ensure that the organization is well-prepared for regulatory and accreditation surveys and meets all regulatory agency requirements. The EH Chief of Regulatory Readiness and Medical Affairs directs and oversees any on-site Joint Commission accreditation, verification and/or Complaint Survey processes. The EH Chief of Regulatory Readiness and Medical Affairs also guides and assists with the coordination of Joint Commission specialty certification surveys. The EH Chief of Regulatory Readiness and Medical Affairs is available to offer support and guidance during regulatory and accreditation surveys for individual hospital services. The EH Chief of Regulatory Readiness and Medical Affairs focuses on the Essentia Health Mission to make a healthy difference in patient’s lives and is committed to the aspirational aims of Essentia Health: Engaged and Inspired People, Zero Preventable Harm and Achieve Health and Vitality with our communities.

Specific Duties and Essential Functions:

• Demonstrate in-depth knowledge of CMS and other government regulations and The Joint commission standards impacting the medical practice and clinic and hospital operations. Serves as a consultant to the organization regarding such standards, conditions, and regulations.

• Provide over-arching proactive regulatory strategy for Essentia Health.

• Lead EH system response to Joint Commission, Public Health, CMS and other regulatory and accreditation bodies.

• Ensure compliant and timely operational execution of all required regulatory updates, submissions, and reporting responsibilities.

• Coordinate drafting of all key EH regulatory documents.

• Interpret policies and procedures authored by the EH Chief of Regulatory Readiness and Medical Affairs as applied to specific clinical and operational cases and situations.

• Provide ongoing orientation, education, training, communication, and support to the designated Chiefs of Staff and Chief of Staff Elect and Medical Staff Executive Committees throughout EH Hospital locations.

• Work with Medical Staff Executive Committees, Chiefs of Staff, Chief of Staff – Elect, and Physician and Professional Staff Services to insure that all Medical Staffs have workable Medical Staff Bylaws, Rules, Regulations, Medical Staff Policies, Peer Review Policies, and Credentialing Policies that are compliant with all regulations and accreditation standards.

• Works collaboratively with Legal Department, Risk Management Director and Executive Administration.

• Provides consultation to all Hospital Medical Staffs and Chiefs of Staff regarding Medical Staff issues and the application of Medical Staff Bylaws, Rules, Regulations and Policies to situations encountered by the Medical Staffs.

• Responsible for communication and education regarding ongoing CMS and other regulatory updates.

• Assures compliance with Joint Commission Medical Staff Standards, CMS Conditions, and applicable State laws regarding the Hospital Medical Staffs, including Bylaws, Rules, Regulations; Credentialing and Privileging; Focused Professional Practice Evaluation (FPPE), Ongoing Professional Practice Evaluation (OPPE), and peer review; graduate medical education; clinical quality oversight and performance improvement; formal corrective action and fair hearing and appeal; and physician health and disruptive behavior issues.

• Provides guidance regarding accreditation and regulatory standards and conditions by serving as a member of key Essentia Health Committees as requested.

This position can be located in Fargo, ND, Brainerd, MN or Duluth, MN