This position is incentive eligible.
Job Summary and Qualifications
The Internal Audit Department provides an independent appraisal function to validate management control systems and to support corporate management in the effective discharge of their responsibilities and efforts to achieve the Company's overall mission. The Clinical Compliance Team work includes a variety of audits and performs onsite and/or remote assessments of focused areas within HCA Healthcare hospitals which include maintaining accreditation (i.e., The Joint Commission (TJC)), federal, state, and local regulations, emergency services, nursing services, etc. Audits also include testing of medical record documentation and corresponding bills to ensure compliance with company policies and government regulations. The purpose of the audits is to assist facility management in determining compliance with company-defined processes and CMS requirements. The team works closely with facility, division, and group management as well as corporate responsible personnel to help effect overall compliance. The Regulatory Accreditation and Safety Compliance Director position will work on various audit engagements with team members at various levels and receive formal evaluations once a year.
What you will do in this role:
• Demonstrates a thorough understanding of The Joint Commission (TJC), The Centers for Medicare and Medicaid Services (CMS), federal and state regulations.
• Performs onsite and/or remote focused assessments of regulatory and accreditation compliance including applicable federal, state, and local regulations and standards, emergency services, nursing services, and other clinical areas of organizational and/or patient safety and risk at HCA Healthcare facilities.
• Conducts reviews of hospital/center systems to ensure compliance with applicable legal, regulatory and licensure requirements as defined by TJC, CMS, federal and state regulations and company policy for areas such as emergency services, nursing services, and other clinical areas of organizational and/or patient safety and risk.
• Understands HCA Healthcare's business and the healthcare industry from a global perspective by recognizing business trends and emerging technical and industry developments of relevance and communicates these to the client engagement team and applicable management personnel.
• Discusses complex auditing issues with engagement team and client management.
• Communicates the objectives of each review and planned other services to the client engagement team and establishes/communicates team members' roles in the process.
• Executes audit procedures, analyzes evidence, reaches conclusions, identifies issues, develops strategies, and makes decisions for complex, judgmental issues related to the review procedures executed. Consults with others in the Company, as necessary, on complex issues.
• Reviews working papers and memoranda for consistency with applicable authoritative guidance and the requirements of the department.
• Develops detailed reports specifying compliance issues identified during the audit.
• Assists the facility with action plan development, follow-up questions. Completes process follow-up as necessary.
• Provides input and guidance in the development of, as well as the review of the detailed audit/review programs particularly focusing on complex audit issues.
• Participates in the audit quality assurance program.
• Assists with educational and administrative matters (e.g. professional development programs, process improvement team initiatives, recruiting efforts, and special projects as requested by the Director).
What qualifications you will need:
• Active RN Licensure with 10 or more years' experience required.
• BSN (from accredited School of Nursing) required.
• Master's degree preferred.
• Experience, and/or certification supporting regulatory/accreditation/safety compliance required.
• Nursing management/supervisory experience preferred.
• Ability to travel up to 50%.
