Job Requisition: REGUL001757
Employment Type: Full-Time
Shift: Days
Hours Per Week: 40 hour/week
Hiring range: $84,094.40-$102,481.60
The actual compensation for this position will be determined based on experience and other factors permitted by law.
Responsibilities:- Compliance and Readiness:
- Maintain ongoing readiness for accreditation surveys from organizations like The Joint Commission (TJC).
- Ensure the hospital meets and maintains compliance with accreditation standards and regulatory requirements.
- Develop, maintain, and implement organizational unannounced survey plans.
- Maintain the Medical Center's Audit and Tracer Program including on-site validation inspections to all clinical locations.
- Implements an ongoing organizational needs assessment for regulatory compliance, including preparation of the periodic performance review for accreditation surveys. Recommendations are made based on the needs assessment.
- Documentation and Record Keeping:
- Manage and maintain all files and data entry for compliance with accreditation requirements.
- Review and analyze data, investigate complaints, and prepare documentation.
- Maintain standards files, including primary and secondary proofs of compliance.
- Prepares documents for surveys to submit post visit including the accreditation response, appeal, and action plan. Continue to track progress against any applicable actions taken under the plans.
- Perform audits on compliance r/t areas of improvement as identified by surveys or internal tracer
- Survey Management:
- Plan and coordinate accreditation and/or regulatory surveys.
- Serve as a liaison between accreditation/regulatory bodies and the organization.
- Manage onsite accreditation and regulatory surveys, including triaging presentation of surveyors and directing.
- Consultation and Education:
- Provide consultation to all departments on the interpretation and application of accreditation standards.
- Organize mock surveys to ensure readiness.
- Educate staff on accreditation requirements and best practices.
- Conduct educational sessions for providers and staff on compliance, risk and safety related topics.
- Collaboration:
- Work closely with hospital leadership and other departments to implement and maintain standards.
- Collaborate with surveyors during site visits.
- Works with Memorial Campus on Behavior Health / Justice Center events and conducts IRC's monthly to ensure case review and safety initiatives are implemented.
- Policy Management
- Work closely with hospital leadership and other departments to implement and maintain standards.
- Collaborate with surveyors during site visits.
- Works with Memorial Campus on Behavior Health / Justice Center events and conducts IRC's monthly to ensure case review and safety initiatives are implemented.
Minimum Qualifications:- Bachelor's degree in nursing
- Minimum three (3) years' experience in a hospital or healthcare related setting with a minimum of two (2) years in quality, risk or regulatory compliance required.
- Demonstrated experience with The Joint Commission (TJC) and other regulatory agencies or certification survey processes required
- Clinical experience to provide understanding of clinical terms and roles as well as ability to navigate the EMR.
- Comfort in clinical settings as observer for audit of real-time clinical processes
- Proficiency with reading, analyzing and applying data sets from specific platforms used in the organization
- Provides clear, concise written and verbal communication.
- Attention to detail, organizational skills, and ability to prioritize tasks in a fast-paced environment
- Proficiency in using data platforms and Microsoft Office applications.
Certifications / Licensure - Nursing License state of New York
Required Skills and Attributes - Ability to organize and establish day-to-day priorities while using critical thinking skills in all aspects of the job.
- Must be able to multitask while remaining professional, focused, composed and positive.
- Excellent customer service skills
- Displays integrity, friendliness, and compassion.
- Must be able to establish an appropriate and effective rapport with others.
- Demonstrates flexibility
- Takes initiative
- Able to work in a fast-paced environment
- Embraces new opportunities to grow both personally and professionally.
- Effective critical thinking and problem-solving skills.
- Proficient with various Microsoft Office products (Word and Excel).
- Strong organizational skills.
- Effective interpersonal skills.
- Ability to take and follow direction in a positive and appropriate manner.
- Ability to work as part of a team and independently. Must be able to demonstrate effective and appropriate written and oral communication skills.
- Must be able to speak, read, write and follow instructions in English.
