General Purpose

This position provides support and education for clinical and non-clinical programs with emphasis on Infection Control and Disease Prevention.

Essential Duties
• Develop, implement, educate and monitor clinical programs that are intended to meet Professional Nursing Standard of Care and Nursing Standard of Practice per the applicable State Board of Nursing and the American Nurses Association.
• Advise and support facilities in their efforts to comply with State and Federal Survey Regulations for Medicare and Medicaid Licensure and Certification, with special focus on Infection Prevention, Control & Immunization.
• Assist facilities in response to endemic, epidemic, & pandemic disease outbreaks.
• Assist the Administrator and/or DON in writing plan of corrections (POC) and Allegation of Compliance (AOC) for any state and federal survey deficiencies cited. Review POC and AOC documents prior to submission.
• Monitor facilities compliance with POC's submitted to State Health Department (HD) for recertification of Medicare and Medicaid License.
• Provide oversight for reportable events that are submitted to HD which includes: reviewing and approving reportable documents sent to HD and assisting facility in correction of issues identified.
• Provide training to facility Administration and/or staff as needed to help them meet Professional Nursing Standard of Care and Nursing Standard of Practice per the applicable State Board of Nursing and the American Nurses Association; and State and Federal Survey Regulations for Medicare and Medicaid Licensure Certification.
• Assist Administrator with hiring, training and disciplinary actions for the Director of Nursing (DON).
• Conduct monthly Regional DON meetings for clinical program training and DON development.
• Assist facilities with their clinical, MDS, dietary, social services and regulatory policies and related education.
• Assist DON in determining appropriate staffing structure and nursing PPD.
• Conduct visits to the facility to assess and train clinical staff. Create action plans as needed to facilitate growth and development.
• Attend regional meetings and give clinical insight as requested by the RVP.
• Provide oversight and direction to the MDS department.
• Conduct Regional monthly MDS meetings for training and CMI development. Monitor and assist as needed, RAC audits received from Insurance, State or CMS.
• Develop Regional tracking and trending reports for clinical metrics regarding CMS 5-star rating. Assist facilities in improving 5-star rating in all categories.
• Assist facilities in their clinical risk management efforts. • Assist facility defense attorneys as needed with lawsuits, depositions, reports and document production as requested.
• Review record requests for appropriate documents for release.

Supervisory Requirements

This position will have supervision responsibilities and clinical oversight.

Education and/or Experience Required

Bachelor's Degree in Nursing (BSN) or equivalent Accredited Nursing Program Degree

Master's Degree in Nursing preferred

20+ years of Clinical and Management experience preferred.

Preferred experience: MDS certified, Legal Nurse Consultant or Risk Management experience; previous Regional or Corporate Nurse experience; experience with CMS/OIG surveys including Jeopardy citations. PCC knowledge

Language Skills

Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations. Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions from managers and employees.

Certificates, Licenses, Registrations

Professional License must remain active and in good standing at all times with the State Board of Nursing. To perform this job successfully, an individual must be proficient in the Microsoft Suite products.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

The employee must occasionally lift and/or move up to 25 pounds. Prolonged use of a desktop or laptop computer. While performing the duties of this job, the employee is regularly required to sit, stand; walk and talk, read or hear. Frequent use of all office related equipment to include; copier/scanner/fax, telephone, and a calculator.

Travel by auto or airline will be required.

Pay Range: $145,000 - $150,000 annually