Fairview Health Services Senior Regulatory Specialist in St. Paul, Minnesota


Fairview Health Services is looking for a two (2) senior regulatory specialists to work within the Fairview and HealthEast system. The primary work locations for these roles will either be at our corporate Energy Park office in Saint Paul or at Bethesda Hospital in Saint Paul. This is a full-time position working day hours, Monday thru Friday.

This position advises all M Health Fairview Health Services entity leaders and staff on matters related to compliance to Joint Commission (JC) standards, Centers for Medicare and Medicaid Services (CMS) regulations and other regulatory requirements (MDH, NFPA, OSHA, ASHE, APIC, etc.). Serves as the internal corporate representative along with the System Regulatory Manager on activities supporting the accreditation and regulatory compliance function.

Responsibilities/Job Description

  • Identify and integrate new and changing regulatory requirements into the healthcare system relating to JC, CMS, DHS, MDH and other regulatory and accreditation bodies.

  • Manage the Accreditation Management Program (AMP) (this is a computerized tool to assist the organization in preparation for regulatory surveys) to include: Design and direct effective implementation of reporting processes; direct the effective AMP education, training, use of the tool and registration of new users, design and communicate assessment tools, techniques and processes for entity use; perform tracers utilizing tools that have been developed; meet with applicable entity/system groups to vet and receive system approval for defined tracers; and create reports for system and per entity to be given to the Board of Directors and other senior leaders that contain defined data elements to track compliance with JC/CMS standards.

  • Identify functions that are best addressed at a system level to achieve success and result in reduced re-work, resources and cost.

  • Manage problem-solving processes when they relate to system accreditation or regulatory issues.

  • Consult with system groups on clinical issues/policies as required (i.e. restraint/pain management, etc.). Member of System Clinical committees such as Provision of Care, Inpatient Clinical Quality, Discharge group, etc.

  • Participate in conducting mock surveys/tracers at all system accredited entities at least annually to assure compliance with standards; provide written reports of all findings and assist facilities in completing action plans; input results into AMP.

  • Partner with leaders and the data/informatics team to design effective regulatory measurement plans when needed to assist in prioritizing and monitoring regulatory improvement activities.

  • Provide back-up on-site assistance to all entities throughout JC, CMS and other surveys as applicable.


Required Qualifications

  • Bachelor of Science/Arts degree in related healthcare field

  • 3-5 years’ experience working with accreditation and regulatory compliance in a clinical setting including experience in working with physicians, leaders and staff with accountability for improvements and outcomes

  • Experience in a clinical work environment/background

  • Experience and accountability working in or with a multi-size, integrated health care delivery system

Preferred Qualifications

  • Master’s degree in health-related field

  • Any Regulatory certification (e.g. CCMSCP, CPHQ, other)

Other Required Skills

  • A broad base of knowledge in the following areas:

  • JC standards and processes for all health care delivery system components (hospital, ambulatory, home care, home medical equipment, behavioral)

  • Conditions of Participation (CoP/Centers for Medicare & Medicaid Services – CMS) regulations

  • Performance Improvement theory and processes

  • Project management

  • Strong computer skills (Microsoft Word, Excel, PowerPoint)

  • Laws, regulations and standards that impact M Health Fairview and each of its entities\

  • Strong interpersonal skills to train and work with many individuals in all entities

  • Clinical knowledge base with review and assessment of clinical records and data

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Fairview Health Services (fairview.org) is an award-winning, nonprofit health system providing exceptional care across the full spectrum of health care services. Joined by HealthEast in June 2017, Fairview is one of the most comprehensive and geographically accessible systems in the state, with 12 hospitals—including an academic medical center and long-term care hospital—serving the greater Twin Cities metro area and north-central Minnesota.

Its broad continuum also includes 56 primary care clinics, specialty clinics, senior living communities, retail and specialty pharmacies, pharmacy benefit management services, rehabilitation centers, counseling and home health care services, medical transportation, an integrated provider network and health insurer PreferredOne. In partnership with the University of Minnesota, Fairview’s 32,000 employees and 2,400 affiliated providers embrace innovation to drive a healthier future through healing, discovery and education.

EEO/AA Employer/Vet/DisabledAll qualified applicants will receive consideration without regard to any lawfully protected status.

Requisition ID 2019-28485

Profession Non-Clinical Professional

Speciality Professional-Non Clinical

Location Fairview Corporate

Shift day

Hours per 2 weeks 80

Department Performance Improvement