The Vice President of Regulatory Affairs, Risk Management and Patient Centered Services reports to the President of VCU Medical Center and is responsible for VCU Health’s overall strategic direction for Regulatory Accreditation and Licensure, Risk Management, and Patient Centered Services. The role is responsible for ensuring VCUHS complies with all complex healthcare regulations, manages risk effectively, and maintains a high level of patient experience and service culture in line with VCU Health Systems mission and vision.

Essential Job Statements

• Ensure VCU Health System complies with all accreditations, federal and state regulatory and licensing standards, including but not limited to, The Joint Commission, Center for Medicare and Medicaid Services, FDA, OSHA, Virginia Department of Health and Virginia Department of Behavioral Health and Development Services  

• Develop, implement, and update policies and procedures to ensure compliance with healthcare regulations and industry best practices.   

• Identify, assess, and mitigate risks within VCUHS, including clinical risk, financial risks, and legal risks.  This includes but is not limited to developing risk management strategies and protocols.  

• Ensure VCU Health System enhances and continually improves the overall experience of patient and families. Develop and support a data driven program to effectively manage all patient experience /service excellence initiatives.  

• Ensure the development and implementation of risk management education, protocols, and programs to prevent adverse events and improve patient outcomes.  This includes investigating and reporting on incidents and adverse events.   

• Conduct regular audits and assessments to ensure compliance with regulations, policies, and procedures. Address any identified compliance gaps or issues. 

• Provide strategic direction on preparation for, coordination of, and response to inquiries/follow-up from surveys, audits, and reviews, ensuring a high level of awareness and compliance with accrediting and federal agency requirements throughout the health system, including ramifications of failures in compliance.  

• Serve as the primary point of contact between VCUHS and regulatory agencies, responding to inquiries, and participating in regulatory surveys and inspections. 

• Develop and monitor actions to address individual and aggregate trends to ensure adherence to all regulatory requirements. Evaluate effectiveness of corrective actions for identified problems and continuous quality improvement activities. 

• Promote ethical behavior and a culture of compliance within the organization, including addressing concerns related to fraud, waste, and abuse. 

• Ensure responsibility and visible commitment of diversity equity and inclusion programs/initiatives through collaboration and implementation of initiatives across the health system.   

• Demonstrate a commitment to the mission of VCUHS as evidenced by performing other duties as assigned and/or participating in special projects or assignments to support the mission of the health system.  Provide assistance to team members.  Accepts alternate assignments, as required. 

Patient Population 

Not applicable to this position.

Employment Qualifications 

Required Education: 

Master’s Degree in a healthcare related field from an accredited school. 

If master’s degree is not in Nursing, then it is a requirement to have a Baccalaureate Degree in Nursing from an accredited school. 

Preferred Education: 

Master’s degree in nursing, Healthcare Administration, Health Law, Public Health, or Business Administration from an accredited program. 

Licensure/Certification Required: 

Current RN Licensure in Virginia or eligible or compact state required.  

Certified Professional in Healthcare Quality (CPHQ) or Certified Professional in Healthcare Risk (CPHRM) or Certified Joint Commission Professional (CJCP) required within 3 years of hire 

Licensure/Certification Preferred: 

Diversity Equity and Inclusion certification preferred 

Minimum Qualifications 

Years and Type of Required Experience 

Required: 10 years of progressive leadership in Regulatory Affairs/Accreditation, or Health Administration experience, including 5 years of Management experience.  

Other Knowledge, Skills and Abilities Required: 

Previous experience with developing and implementing CMS-2567 Corrective Action Plans, Joint Commission Evidence of Standard Compliance, and new programs.  

Thorough knowledge of regulatory and accreditation requirements (TJC, CMS, VDH, DBHDS, OSHA) 

Previous experience with managing unannounced accreditation and regulatory surveys.  

Previous experience with compliance requirements for hospital accreditation and disease specific certification  

Cultural Responsiveness 

Demonstrate a commitment to diversity, equity, and inclusion through continuous development, modeling inclusive behaviors, and proactively managing bias.  

Other Knowledge, Skills and Abilities Preferred: 

Experience in transformation and change leadership.   

Previous experience in an academic medical center environment  

Experience in leading process improvement initiatives as well as teaching and coaching new leaders.  

Working Conditions 

 
Periods of high stress and fluctuating workloads may occur.   

General office environment.   
Required to car travel to off-site locations, occasionally in adverse weather conditions.

May have periods of constant interruptions.  

Physical Requirements   

Physical Demands: Lifting/ Carrying (0-50 lbs.)

Work Position: Sitting, Walking

Additional Physical Requirements/ Hazards    

Physical Requirements: Repetitive arm/hand movements, Acuity - far, Acuity - near   

Hazards:

Mental/Sensory – Emotional     

Mental / Sensory: Strong Recall, Reasoning, Problem Solving, Hearing, Speak Clearly, Write Legibly, Reading, Logical Thinking 

Emotional: Fast-paced environment, Able to Handle Multiple Priorities, Able to Adapt to Frequent Change 

Workday Day (United States of America)

EEO Employer/Disabled/Protected Veteran/41 CFR 60-1.4.