Covenant Health · 7 hours ago
Regulatory Specialist, Quality Management
Morristown, TN
Full-time
Onsite
Senior Level
5+ years expCovenant Health is a healthcare provider with a focus on patient care and regulatory compliance. The Regulatory Specialist, Quality Management is responsible for ensuring compliance with regulations from The Joint Commission, CMS, and other agencies, while coordinating educational updates and survey readiness activities.
Health CareHealth InsuranceHome Health Care
Responsibilities
Provides direction and support to organizational leaders and staff in all areas of regulatory compliance through training and the review, summarization, and dissemination of updates
Develops, implements, and maintains a variety of specific plans and processes, addressing related administrative issues that may be linked to program and project responsibilities, and coordinates actions with other operational groups such as Chief Nursing Officers, Information Systems, Infection Preventionists, Facility Management, Facility Senior Leader Teams, etc
Responsible for organizing ongoing review of local policies, updating the local policy site, summarizing policy changes to leadership, and providing input on system policies related to regulatory functions
Collaborates with education to develop and implement educational programs to ensure successful completion of survey visits
Remains current with Joint Commission, CMS, and the state of Tennessee regulations in addition to applicable licensing requirements
Implements processes and internal audits to ensure the facility remains in a state of continuous readiness
Responsible for providing a monthly update, and as needed updates, to leadership of any new or potential regulatory compliance concerns
Responsible for ensuring completion of an FMEA at the facility level at least every 18 months
Directs the activity related to yearly focused standards review and is responsible for overseeing the completion
Responsible for ensuring education and use of Joint Commission Resources products in the facility
Determines schedules and oversees completion of tracer activities and mock surveys on a regular basis
Works in collaboration with Regulatory Specialist for Engineering and Human Resources, Infection Prevention Teams, Medical Staff Office, and Environment of Care Teams to ensure coordination or continuous survey readiness through regulatory compliance. Conducts regular departmental rounds
Works directly with the System Director of Quality and Patient Safety to ensure system safety and reliability
Represents the facility onsite during any Joint Commission, CMS, or state survey. Assists with other types of regulatory and certification surveys as deemed necessary by Administration
Local travel required
Follows policies, procedures, and safety standards. Completes required education assignments annually. Works toward achieving goals and objectives, and participates in quality improvement initiatives as requested
Performs other duties as assigned
Qualification
Required
Bachelor's degree in Nursing OR Associate's degree in Nursing with two (2) years' experience in a quality department
Five (5) years' experience in a hospital setting
Able to demonstrate knowledge of Joint Commission standards and Medicare Conditions of Participation
Proficient in the use of Microsoft Office applications
Excellent organizational and communication skills required
Must have and maintain Tennessee State RN licensure
Employee must have a valid Tennessee driver's license and state mandated minimum insurance coverage
Driving record must meet Covenant Health minimum standards at the date of hire and throughout employment tenure
Preferred
Master's preferred
Previous experience in overseeing regulatory compliance in a facility preferred
Company
Covenant Health
Covenant Health is a top-performing healthcare network company located in Knoxville.
10001+ employees
Funding
Current Stage
Late StageLeadership Team
Jim VanderSteeg
President and CEO
Recent News
Morningstar.com
2025-12-19
Morningstar.com
2025-10-02
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