Job Description

** Principal Responsibilities and Tasks**

The following statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all job duties performed by personnel so classified.

1. Ensures compliance with Regulatory Quality programs.

• Ensures compliance with external regulators and accrediting agencies (e.g. The Joint Commission, Centers for Medicare and Medicaid Services (CMS) and Maryland State Department of Health and Mental Hygiene).
• Ensures compliance for special designations (e.g. PARC).
• Ensures that Medical Center and department policies, procedures and standards meet requirements and regulations of regulatory and accrediting agencies. Provides mechanism for continuous review of above.

2. Ensures measurement strategies exist to demonstrate regulatory and accrediting compliance. Collaborates with Director, Quality Improvement nurses, School of Medicine quality forums, Medical Staff sub-committees and hospital departments to develop, implement and evaluate review processes.

3. Leads participation in State and Federal Quality projects to obtain comparative data on quality and regulatory indicators (e.g. MHA Quality Indicator Project).

4. Coordinates/participates in regulatory and accrediting visits and inquiries.

• Coordinates on-site visits for Maryland State Department of Health and Mental Hygiene, CMs, and TJC to investigate patient care issues/complaints.
• Responds to correspondence re: patient care issues/complaints in collaboration with physician and hospital staff.
• Participates and assists in preparing the hospital for The Joint Commission visits and state licensure surveys.

5. Staffs key hospital committees related to Regulatory Compliance

Qualifications

• Bachelor’s degree in Nursing (BSN) is preferred; or other Healthcare degree and current license
• Five years of progressively responsible professional experience performing quality compliance review strategies or equivalent is required.

Additional Information

All your information will be kept confidential according to EEO guidelines.

Compensation

• Pay Range: $31.78-$44.5
• Other Compensation (if applicable):
• Review the 2025-2026 UMMS Benefits Guide

Like many employers, UMMS is being targeted by cybercriminals impersonating our recruiters and offering fake job opportunities. We will never ask for banking details, personal identification, or payment via email or text. If you suspect fraud, please contact us at careers@umms.edu.