SISTERS OF PROVIDENCE HEALTH SYSTEM
TITLE: Regulatory Compliance Coordinator FLSA: Exempt
DEPARTMENT: Regulatory Compliance GRADE: 114
FACILITY: Mercy Medical/Providence/Brightside DATE: December 2011
JOB SUMMARY:
PRIMARY JOB RESPONSIBILITIES AND DUTIES:
1. Assumes responsibility for the review of regulatory data as it relates to JC standards and other regulatory bodies. Assists the Director of Regulatory Compliance with preparation and coordination of all JC survey processes including but not limited to mock survey (internally and with external consultants); applications, agenda, and all interviews.
2. Assists the Director with all State of Massachusetts license visits including but not limited to the Department of Public Health (DPH) and the Department of Mental Health (DMH). Collaborates with Department Managers and their staff to prepare and maintain the State of Massachusetts regulations.
3. Assists the Director of Weldon Rehab with the C.A.R.F. tri-annual survey visits. Collaborates with the Weldon staff to prepare and maintain the C.A.R.F. accreditation.
4. Assists with the management of monitoring and evaluating the hospital for compliance with regulatory bodies. Assures that all mandatory monitoring is collected, analyzed and updated. Ensures confidentiality of all performance improvement, quality assurance, and regulatory data.
5. Monitors changes in all regulatory standards, communicates them and reviews for compliance. Collects and /or coordinates data to assess Measures of Success. Conducts and coordinates "mock Tracers" for educational and assessment purposes. Assists managers and staff in clarifying standards with implementation and ongoing assessment.
6. Collaborates with all department mangers and Department of Education to maintain a current state of "survey readiness".
7. Identifies process to enter data into a software program. Analyzes data for trends and areas of noncompliance. Develops corrective actions.
8. Maintains a performance improvement function that exceeds JC and other external regulatory agencies requirements. Compiles department regulatory compliance profiles and assures accuracy of all data included in the reports.
9. Assists the Director with the annual JC self-assessment process, including review of all quarterly updates. Identifies all standards that need ongoing monitoring in order to ensure compliance.
10. Oversees implementation of policies, procedures, objectives and regulatory improvement activities.
11. Communicates effectively, orally and in writing, when dealing with physicians, nurses, and allied health professionals under the direction of the Manager.
12. Positively interfaces with peers and medical staff to facilitate and influence change. Shows tact and diplomacy in dealing with others to provide an environment conducive to confidentiality, cooperation and team effort, and also communicates with coworkers to resolve conflicts and maintain good working relationships. Acts as a resource to staff/departments in sharing knowledge of regulatory compliance standards and implementation.
13. Promotes professionalism by demonstrating a commitment to continued professional development by seeking to extend knowledge and improve skills through reading health care publications and staying current on new legislation, standards and national trends.
REQUIRED KNOWLEDGE, SKILLS AND ABILITIES:
1. B.S.N. required; current licensure required as a Registered Nurse in the Commonwealth of Massachusetts.
2. Minimum of three years of acute care experience and one-year recent experience in regulatory compliance, including knowledge of the Comprehensive Accreditation Manual for Hospitals (JC). Minimum of one-year recent experience with the Commonwealth of Massachusetts regulations (CMR), and the Department of Mental Health. Knowledge of regulatory compliance standard interpretations including self-assessment tools and processes required.
3. Work requires extensive computer knowledge and experience as well as knowledge and demonstrated excellence in the use of various software programs.
WORKING CONDITIONS:
1. Requires light physical effort on a regular basis, as in frequent walking, bending, reaching and/ or occasional lifting of light items (i.e. up to 20 lbs). Work requires ability to reach and grasp objects.
2. Periodic eye and ear strain (less than 50% of the time). Work requires ability to communicate orally. Work requires proofreading and checking documents for accuracy.
3. Some minor physical inconvenience or discomfort routinely present in the work situation (moderate noise, disagreeable odors, etc.)
4. Occasional exposure to minor injury or other occupational hazards requiring precaution.
REPORTING RELATIONSHIPS:
1. Reports to the Director of Regulatory Compliance.
2. Has no responsibility for the direct management of staff.
Please apply online at http://mercycares.com
The above is intended to describe the principal responsibilities and outcomes, and the associated requirements, as well as the work environment. It is not intended as an exhaustive list of all aspects of the job.