How would you like to work in a place where your contributions and ideas are valued? A place where you can serve with compassion, pursue excellence and honor every voice? At Wellstar, our mission is simple, yet powerful: to enhance the health and well-being of every person we serve. We are proud to have become a shining example of what's possible when the brightest professionals dedicate themselves to making a difference in the healthcare industry, and in people's lives.

Work Shift

Job Summary:

The Regulatory Affairs Program Coordinator (RN) supports the Manager of Regulatory Affairs in various continual
readiness and accreditation/regulatory compliance activities, including assisting with mock surveys. This position is
responsible for the coordination of self-tracers, and for conducting process tracers including developing tracers,
collecting, analyzing, and reporting tracer findings. This Coordinator uses their clinical expertise to advise and
successfully collaborate with various levels of personnel including leaders, physicians, and team members.

Core Responsibilities and Essential Functions:

Maintains current knowledge of requirements related to CMS Conditions of Participation, The Joint
Commission, the Georgia Department of Public Health, and other governing bodies. Interprets regulations,
licensure standards, and accreditation standards with an emphasis on the hospital, laboratory, and
ambulatory care expectations.
Develops and delivers education regarding internally and externally driven trends in healthcare licensure,
accreditation, and regulatory compliance. Assists managers and staff with workflow development, policy
and procedure review/revision, mock survey assessments, and continuing education.
Works in conjunction with the Manager as well as hospital and clinic leaders, medical staff, and allied health
staff to identify, prioritize and mitigate accreditation and regulatory compliance risks and opportunities.
Partners with operational leaders and departments to develop corrective action plans and to track the
success of corrective action plans.
Uses clinical expertise to conduct tracers and audits of documentation and processes. Assists clinicians in
improving processes and compliance to regulatory standards.
Gathers and submits necessary documents to support the maintenance of and changes to accreditation
application. Provides support to Manager and Director during pre-survey preparation, on-site survey, and
post-survey follow up activities.
Performs other duties as assigned
Complies with all Wellstar Health System policies, standards of work, and code of conduct.

Required Minimum Education:

• Associates Nursing or Bachelors Nursing-Preferred

Required Minimum License(s) and Certification(s):

All certifications are required upon hire unless otherwise stated.

• RN-Compact or RN - Reg Nurse (Single State)

Additional License(s) and Certification(s):

CPHQ Preferred.

Required Minimum Experience:

Minimum 2 years Acute care setting as a clinician/registered nurse. Required or
Minimum 5 years Acute care setting as a clinician/registered nurse. Preferred

Required Minimum Skills:

Computer skills required to include Microsoft
Word, Excel and PowerPoint, Data
Abstraction and Management. High

Join us and discover the support to do more meaningful work—and enjoy a more rewarding life. Connect with the most integrated health system in Georgia, and start a future that gives you more.