ELIGIBLE FOR CMH EMPLOYEE REFERRAL BONUS: NON-PRIORITY RECRUITMENT The Accreditation, Regulatory, and Licensing Nurse Specialist ensures compliance with licensing, accreditation, and regulatory requirements for new, expanding, and existing facilities and services. This role stays up to date on relevant accrediting standards and consults with departments to ensure proper certification, conducting basic gap analyses for both standard and nonstandard cases. As the subject matter expert, this position: • Maintains internal policies and oversees organizational compliance. • Develops and delivers educational programs to align policies with regulatory requirements. • Monitors compliance and regularly meets with departmental leaders to ensure adherence to regulations and accreditation standards. • Provides education to leadership on accreditation processes and regulatory and/or accreditation changes. • Arranges and leads mock surveys to prepare for accreditation reviews. • Maintains a master list of all accreditations held by CMH with associated due dates for revalidation. Job Requirements Knowledge of/Skill/Ability to: Serves as the subject matter expert for regulations within assigned areas by: maintaining and beginning to facilitate awareness of current internal policies and relevant external regulations, with occasional review; attending committees and actively contributing consultative guidance on the enforcement of regulations and survey processes; and developing standard and nonstandard content and delivering educational programs to align organizational policies and procedures with regulatory requirements. Responsible for compliance with policies within the organization. Ensuring that policies are appropriately approved by the committee in a timely manner. Working with department managers to manage policies, providing guidance on policies that can be archived or combined. Administering policy management system. Training new leaders on policy workflows and system. Ensures licensing and accreditation by: reviewing ongoing licensing and accreditations for new, existing, and expanding facilities/services to aid in achievement of compliance with state, federal, and accrediting standards, with regular review; consulting with other departments to ensure certification for standard and nonstandard cases; and independently conducting a basic gap analysis and mentoring others to identify services renewals and planning to ensure services are compliant. Conducts regulatory audits and surveys by: independently planning for completion of assigned report and keeping current on regulatory requirements in preparation for surveys (e.g., CMS, ACHC, and other regulatory surveys), with regular review from manager(s); assisting with on-site visits and evaluations as directed; leveraging strategies and guidelines to review, evaluate site visit criteria, and perform site visits as appropriate to ensure survey readiness, independently; and preparing requested audit documentation, information, and reports, with regular review; communicating to the manager on the status of survey completion as required for auditing surveys, focusing on high vulnerability areas. License/Certification Required: RN currently licensed by the Oregon State Board of Nursing Preferred: Certified Professional in Healthcare Quality (CPHQ). Preferred: Credential(s) from the Healthcare Accreditation Certification Program(s) (HACP). Preferred: Three (3) years of National Committee of Quality Assurance (NCQA) or related survey experience. Education and/or Experience Associate Degree in Nursing: BSN Preferred Minimum two (2) years of experience with databases and spreadsheets. Physical Demands and Work Environment Conditions / ADA Compliance Sedentary position. Light work. Subject to many interruptions. Must be pleasant in nature and be able to work extremely well under pressure. Must be able to meet deadlines. Must also be able to work very independently with little direction from supervisor. Some evening work required.