GENERAL SUMMARY/BASIC PURPOSE OF JOB:
Develops, facilitates and coordinates quality improvement initiatives as related to regulatory compliance
resulting in improved patient care, operations and patient experience. Collaborates with hospital staff on
initiatives to improve the integrity of the environment of care and emergency preparedness of the
organization. Supports the team with accreditation and regulatory compliance initiatives including the
Environment of Care Committee and Accreditation Committee for the System. The Regulatory
Compliance Specialist will write new and revise existing SHS policies and will assist SHS leadership with
writing departmental procedure, in addition to training all staff within the organization on the policy
program and ensuring leadership has trained staff on new and/or revised guidelines and requirements.
Regulatory Compliance Specialist will also chair and lead the Policy Committee meeting.
ESSENTIAL FUNCTIONS AND DUTIES:
- Directs survey readiness activities that support continuous compliance with
accreditation and governmental regulations, including voluntary, mandatory
and contractual reporting requirements.
- Develops, deploys and leads the chapter lead model for regulatory readiness
for the system.
- Develops, deploys and executes the survey response process to ensure a
dynamic and extraordinary positive experience for surveyors presenting to
survey the organization and the site leaders and frontline staff and providers
being surveyed.
- Maintains “expert” knowledge of standards related to accreditation and
regulatory bodies, i.e., The Joint Commission, CMS, IDPH, CARF, and HFAP.
- Develops, files, and executes plans of correction in follow up to surveys.
- Responsible for keeping abreast of current/changing regulatory reporting
requirements with potential to impact documentation practices and related
training.
- Other duties as assigned
JOB REQUIREMENTS
MINIMUM WORK EXPERIENCE:
2+ year’s healthcare related experience in policy, procedure, documentation and
technical writing or equivalent work experience. Experience in regulatory and survey readiness
and response activities required. Quality & Regulatory experience preferred.
KNOWLEDGE & SKILLS:
Computer skills, including mastery of Microsoft Office products, data analytic software and
modeling, electronic mail and the worldwide web/ internet. Ability to learn new systems
software. Self-motivated and continuous learning capability required.
Knowledge on ICD 10 coding with awareness of risk and mortality adjustment methodologies
Knowledgeable of CMS, AHRQ, CDS and other reportabe agencies clinical performance measures.
Demonstrated knowledge of facilitating and coordinating healthcare improvement projects with
previous quality improvement project experience.
Proven results driven improvement experience preferred
High-level analytic skill in the use of complex quality data in business/value development and
the display of findings is desired.
Excellent oral, written and interpersonal communication skills.
Ability to work independently.
High degree of creativity in problem-solving
REQUIRED LICENSES, CERTIFICATES, REGISTRATIONS:
None
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