St. Mary’s Healthcare has been providing high-quality, compassionate healthcare to the people of Montgomery and Fulton counties since 1903. At St. Mary’s Hospital, the Rao Outpatient Pavilion and other locations, the local, independent healthcare organization offers the comprehensive, critical services its community needs and deserves. St. Mary’s Healthcare has also been named a 2026 Times Union Top Workplace—the first acute care hospital in the Capital Region to earn the distinction since the Times Union launched the recognition program 14 years ago.
Job Requisition: REGUL001757
Employment Type: Full-Time
Shift: Days
Hours Per Week: 40 hour/week
Hiring range: $84,094.40-$102,481.60
The actual compensation for this position will be determined based on experience and other factors permitted by law.
Responsibilities:
- Compliance and Readiness:
- Maintain ongoing readiness for accreditation surveys from organizations like The Joint Commission (TJC).
- Ensure the hospital meets and maintains compliance with accreditation standards and regulatory requirements.
- Develop, maintain, and implement organizational unannounced survey plans.
- Maintain the Medical Center’s Audit and Tracer Program including on-site validation inspections to all clinical locations.
- Implements an ongoing organizational needs assessment for regulatory compliance, including preparation of the periodic performance review for accreditation surveys. Recommendations are made based on the needs assessment.
- Documentation and Record Keeping:
- Manage and maintain all files and data entry for compliance with accreditation requirements.
- Review and analyze data, investigate complaints, and prepare documentation.
- Maintain standards files, including primary and secondary proofs of compliance.
- Prepares documents for surveys to submit post visit including the accreditation response, appeal, and action plan. Continue to track progress against any applicable actions taken under the plans.
- Perform audits on compliance r/t areas of improvement as identified by surveys or internal tracer
- Survey Management:
- Plan and coordinate accreditation and/or regulatory surveys.
- Serve as a liaison between accreditation/regulatory bodies and the organization.
- Manage onsite accreditation and regulatory surveys, including triaging presentation of surveyors and directing.
- Consultation and Education:
- Provide consultation to all departments on the interpretation and application of accreditation standards.
- Organize mock surveys to ensure readiness.
- Educate staff on accreditation requirements and best practices.
- Conduct educational sessions for providers and staff on compliance, risk and safety related topics.
- Collaboration:
- Work closely with hospital leadership and other departments to implement and maintain standards.
- Collaborate with surveyors during site visits.
- Works with Memorial Campus on Behavior Health / Justice Center events and conducts IRC’s monthly to ensure case review and safety initiatives are implemented.
- Policy Management
- Work closely with hospital leadership and other departments to implement and maintain standards.
- Collaborate with surveyors during site visits.
- Works with Memorial Campus on Behavior Health / Justice Center events and conducts IRC’s monthly to ensure case review and safety initiatives are implemented.
Minimum Qualifications:
- Bachelor’s degree in nursing
- Minimum three (3) years' experience in a hospital or healthcare related setting with a minimum of two (2) years in quality, risk or regulatory compliance required.
- Demonstrated experience with The Joint Commission (TJC) and other regulatory agencies or certification survey processes required
- Clinical experience to provide understanding of clinical terms and roles as well as ability to navigate the EMR.
- Comfort in clinical settings as observer for audit of real-time clinical processes
- Proficiency with reading, analyzing and applying data sets from specific platforms used in the organization
- Provides clear, concise written and verbal communication.
- Attention to detail, organizational skills, and ability to prioritize tasks in a fast-paced environment
- Proficiency in using data platforms and Microsoft Office applications.
Certifications / Licensure
- Nursing License state of New York
Required Skills and Attributes
- Ability to organize and establish day-to-day priorities while using critical thinking skills in all aspects of the job.
- Must be able to multitask while remaining professional, focused, composed and positive.
- Excellent customer service skills
- Displays integrity, friendliness, and compassion.
- Must be able to establish an appropriate and effective rapport with others.
- Demonstrates flexibility
- Takes initiative
- Able to work in a fast-paced environment
- Embraces new opportunities to grow both personally and professionally.
- Effective critical thinking and problem-solving skills.
- Proficient with various Microsoft Office products (Word and Excel).
- Strong organizational skills.
- Effective interpersonal skills.
- Ability to take and follow direction in a positive and appropriate manner.
- Ability to work as part of a team and independently. Must be able to demonstrate effective and appropriate written and oral communication skills.
- Must be able to speak, read, write and follow instructions in English.
Required
Equal Opportunity Employer
This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights (https://www.eeoc.gov/poster) notice from the Department of Labor.
