Full Job Description
The Dir-Regulatory/Accr/Compliance will lead the development and implementation strategies for an effective survey readiness program. The program will include monitoring and oversight of the regional community regulatory programs along with the development of education to address problematic regulations as well as survey tactics.
The Dir-Regulatory/Accr/Compliance will assist with integration of Mercy's key clinical safety and quality activities with Joint Commission Standards, CMS Regulations and State Regulations to provide consistent processes across the community. These activities will decrease Mercy's exposure to risks, increase quality patient care and steward Mercy's financial and human resources and perform duties and responsibilities in a manner consistent with Mercy's Mission, Values, and Service Standards.
Position Details:
Education: Bachelor degree in health-related field.
Preferred Education: Masters in Health related field.
Experience: Minimum ten years health care experience in a clinical discipline including at least five years accreditation experience and 5 years leadership/management experience. Specific experience related to accreditation and regulatory bodies, such as CMS and state licensing agencies.
Other: In-depth knowledge of accrediting and regulatory standards with demonstrated ability to interpret standards, serve as a subject matter expert and communicate information to all levels in the organization.
Demonstrated leadership skills with the ability to manage co-workers and prioritize and manage multiple tasks simultaneously.
Excellent communication skills to effective interact with all levels of Caregivers, from senior leaders to front-line caregivers.
- Serve as the regional community primary contact to regulatory and accreditation organizations.
- Provide assistance with building Epic documentation modules to meet regulatory requirement sand key clinical activities.
- Keep abreast of changes in legislation and requirements related to regulatory accreditation and licensing issues.
- Develop a standard approach for assessing regulatory risk across the continuum of care and venues for both existing and new acquisitions.
- Identify key Joint Commission accreditation, CMS regulations and State licensing issues and defines areas for improvement.
- Bring a community view and expertise to patient safety and quality improvement activities thru regulatory activities.
- Provide guidance to ministry-wide and community collaborative groups when appropriate.
- Monitor and provide oversight and review Quality and Safety goals during mock surveys.
- Implements a regional continuous readiness compliance program for all venues of care defining the team structure, process and assessment.
- Education and mentor new mock surveyors.
- Design and conduct on-site mock surveys using Mercy tracer tools and other tools to evaluate and maintain compliance.
- Provide formal training on Joint Commission standards and CMS regulations to organizations when appropriate.
- Identify vulnerability and direct strategies to enhance compliance.
- Share best practices across the region.
- Communicate across the regional community on a regular basis: compliance updates, activities and areas of focus.
- Collaborate and work with key stake holders on regulatory goals; working to develop written policies and procedures to ensure compliance with regulations and standards.
- Support and assist with corrective action plans.
- Provide consultative services to all departments and services regarding the intent of regulations and strategies to maintain compliance.
- Performs other work duties as assigned.
