At BayCare, we are proud to be one of the largest employers in the Tampa Bay area. Our network consists of 16 community-based hospitals, a long-term acute care facility, home health services, outpatient centers, and thousands of physicians. With the support of more than 30,000 team members, we promote a forward-thinking philosophy thats built on a foundation of trust, dignity, respect, responsibility, and clinical excellence.
Your Role within the Team
Ensure Regulatory Compliance Support Joint Commission JC accreditation and certification efforts for the Hospital Division by assisting with compliance to all applicable Joint Commission and Centers for Medicare & Medicaid Services CMS standards.
Facilitate Survey Readiness Coordinate and conduct Joint Commission Tracers Readiness Rounds, audits, and inspections to assess and maintain continuous survey readiness across hospital facilities.
Educate & Engage Leaders Ensure facility administration, directors, and managers are knowledgeable about current regulatory standards, accreditation interpretations, and best practices through education, feedback, discussions, and presentations.
Partner with Hospital Teams Collaborate closely with departmental leadership and hospital Quality Managers to identify opportunities for improvement, address deficiencies, and resolve issues impacting compliance and readiness.
Act as a Regulatory Liaison Serve as a facility liaison with regulatory agencies by communicating with surveyors and consultants and supporting responses to inquiries and surveys.
Promote Education & Training Participate in new team member orientation, quarterly training, and annual Team Member Essentials related to regulatory requirements, promoting awareness and compliance across teams.
Support Standardization Efforts Assist with BayCare-wide initiatives focused on regulatory standardization and best practice alignment.
Leverage Regulatory Systems Serve as the subject matter expert in the use of regulatory software to support compliance tracking, audits, and reporting.
Work Independently & Proactively Manage priorities independently with strong organizational skills, maintaining action plans and follow-up to ensure sustained readiness.
Perform Additional Duties Complete other quality and regulatory activities as assigned under the direction of the Manager.
Qualifications
Required:
Location: Tampa, FL Status: Full-time Exempt Shift Hours: 8am-4pm Shift: Shift 1 Shift 1: Days 2, Evenings 3, Nights 4, Varies Weekend Work: Occasional On Call: No