Job Title: Director Location: RWJUH Somerset Department Name: External Affairs and Policy Req #: 0000207509 Status: Salaried Shift: Day Pay Range: $130,000.00 - $180,000.00 per year Pay Transparency: The above reflects the anticipated annual salary range for this position if hired to work in New Jersey. The compensation offered to the candidate selected for the position will depend on several factors, including the candidate's educational background, skills and professional experience. Job Overview: RWJBarnabas Health is seeking a highly dedicated Director for Quality, Safety and Regulatory for RWJ Somerset Medical Center. Qualifications: Bachelor of Science in Nursing required. Masters preferred Current New Jersey RN Licensure BLS required. (American Heart Association) Professional Certification CPHQ-Certified Professional in Healthcare Quality highly desirable Minimum of five years' experience in clinical practice Prior experience with performance improvement initiatives, and regulatory oversight, Strong leadership, critical thinking, teaching, facilitation, coaching, mentoring and project management skills, Training and experience in performance improvement methodologies, Knowledgeable about state, federal, and regulatory agency requirements, Essential Functions : Actively participates in committee based on organizational needs and requests, Is an active member of the following: Hospital Performance Improvement Committee, Patient Safety Committee and Regulatory Compliance Committee, Consults on Performance Improvement team process and performance , Provides guidance and supervision to improve Performance Improvement and Regulatory matters, Assists in the coordination of all aspects of survey preparation, coordination, management and post-survey follow-up for all regulatory agencies, Ensures the management of the Joint Commission Extranet site for the facility including the application, complaints and all post-survey activity, Assists in the development and implementation of guidelines and new methods to address new regulatory requirements and deficiencies, Works with managers to prepare corrective action plans and conducts follow-up as indicated, Ensures responses are relevant and measurable as applicable according to established regulatory guidelines, Responsible for facilitating timely submission of all written responses to all citations, violations or letters of inquiry for all regulatory agencies, Ensures organizational awareness of The Joint Commission and NJDOH Patient Safety work through the development and distribution of alert-specific self-assessment tools, Utilizes the principles of Performance Improvement in all work situations to assess, measure and improve organizational and departmental functions, Participates in the analysis and appropriate follow-up to sentinel events with the hospital, Facilitates the completion of the Root Cause Analysis for all sentinel events, Participates in the root cause analysis of high risk occurrences within the organization, Assists with the reporting of high risk occurrences the New Jersey Department of Health and Senior Services Patient Safety Initiative, Maintains and demonstrates current knowledge of accreditation and licensing standards and regulations for areas of responsibility, Maintains current body of knowledge related to quality assessment, measurement and Performance Improvement methods, Promotes effective communication and staff education on the intent and interpretation of standards, Provides ongoing monitoring and education to all staff based upon changes in published applicable standards and facility-specific trends, Prepares the Behavioral Health Center and Network for regulatory inspections, surveys and site visits, Oversees all ongoing activities related to the development, implementation, maintenance of and adherence to the organization s policies and procedures to ensure compliance with regulatory standards, Provides oversight for senior management and all departments to meet regulatory standard compliance, Coordinates planning, implementation and evaluation of organizational compliance with all regulatory/licensing standards and ongoing readiness for survey, Responsible for all survey related activity related to complaint investigation, licensing surveys or accreditation surveys by regulatory agencies, Serves as the organization s liaison to regulatory and accrediting agencies, Scheduling Requirements : Full Time 40 hours per week Other Duties: Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice. Benefits and Perks: At RWJBarnabas Health, our market-competitive Total Rewards package provides comprehensive benefits and resources to support our employees physical, emotional, social, and financial health. Paid Time Off (PTO) Medical and Prescription Drug Insurance Dental and Vision Insurance Retirement Plans Short & Long Term Disability L