Regulatory Compliance Coordinator

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Certified in Healthcare Compliance (CHC) Certification

2. Certified Professional in Healthcare Quality through National Association for Healthcare Quality 

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position.  They are not intended to be constructed as an all-inclusive list of all responsibilities and duties.  Other duties may be assigned.

1. Leads in the development and implementation of regulatory activities and monitors indicators for assessment of regulatory compliance.

2. Develops and implements mechanisms for ongoing data collection, analysis, and reporting of regulatory indicators

3. Initiates mechanisms to ensure timely and accurate reporting of data.

4. Monitors appropriate criteria and reports the data for specific procedures and services.

5. Develops performance improvement initiatives throughout the institution.

6. Prepares the institution to successfully meet Joint Commission standards and Centers for Medicare and Medicaid Services (CMS) conditions of participation.

7. Collects data through survey audits of departments, chart review, and staff interviews.

8. Analyzes data for trends and for medical staff and institutional compliance with Joint Commission standards and CMS conditions of participation.

9. Develops and submits reports for appropriate individuals and committees within the organization.

10. Interacts with faculty and staff to present quality initiative updates, reports, and education.

11. Assists in the development of appropriate policies, processes, and activities to support continuous readiness for Joint Commission and Centers for Medicare and Medicaid Services.

12. Prepares the institutional response to Joint Commission and CMS findings. 

13. Prepares and submits evidence of standards compliance to Joint Commission.

14. Ensures timely and accurate monitoring of required measures of success. Submits measure of success to Joint Commission.

15. Updates Senior Administration as to the current status of accreditation.

16. Prepares institutional Annual Periodic Performance Evaluation.

17. Develops assignments for chapter leaders and ensures chapter leaders complete required assignments.

18. Upon completion of annual period performance evaluation, attests to completion and accuracy.

19. Safety & Risk Management duties: Works closely with staff, Administration and/or legal counsel in the event of a issue which arises involving patients, visitors, staff or the facility.  This may result in fact gathering, investigation, review of medical records etc.  Reports, as necessary, will be shared with Administration and the Board of Directors.

20. Emergency Preparedness duties: Directs the planning, coordination and updates for all aspects of the Emergency Management Program and Emergency Operations Plan (EOP) including both internal and external event responses.  Plan, resource and execute all EOP training and exercise events in support of hospital preparedness while coordinating across the hospital staff. Serves as the Hospital representative to local, state and regional hospital preparedness and association committees as required.

PHYSICAL REQUIREMENTS: 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.

1. Frequent walking, standing, stooping, kneeling, reaching, pushing, pulling, lifting, grasping are necessary body movements utilized in performing duties through the work shift.

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Office and hospital setting.

SKILLS AND ABILITIES:

1. Must have computer literacy.

2. Demonstrates assertiveness.

3. Utilizes community and system resources.

4. Must be flexible.

5. Demonstrates effective interpersonal communication.

6. Demonstrates diplomacy.

7. Demonstrates written and verbal skills.

8. Demonstrates negotiation skills.

9. Demonstrates analysis and research methods.

10. Must be able to use Microsoft Word, Excel, Access and other software to collect, analyze, and present data.