Regulatory Compliance Specialist

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 have trained staff on new and/or revised guidelines and requirements. Regulatory Compliance Specialist will also chair and lead the Policy Committee meeting.

REPORTING RELATIONSHIPS:

• Reports to: Executive Director, Regulatory & Patient Safety (Patient Safety Officer)
• Provides Supervision to: None

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.
• Organizes regular meetings of Regulatory Compliance committees or survey preparation groups:
  • Prepares agendas, meeting materials, minutes, and related correspondence.
  • Prepares detailed reports, presentations, and dashboards, presents findings at a variety of quality/regulatory meetings, and facilitates follow-up plans; communicates status of plans to responsible designated individuals.
• Assists in designing, developing, maintaining, and updating the policy software (Policy Stat & SharePoint) based on department and organizational needs.
• Provides staff with initial orientation and ongoing policy and procedure training.
• Updates and maintains the policy and procedures repository.

MINIMUM EDUCATION:

• Bachelor’s degree, preferably in Public Policy or Health Policy or Healthcare field with relevant work experience required.

MINIMUM WORK EXPERIENCE:

• Minimum 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 is required.
• Knowledge on ICD 10 coding with awareness of risk and mortality adjustment methodologies
• Knowledgeable of CMS, AHRQ, CDC and other reportable 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, “platform” and interpersonal communication skills.
• Ability to work independently.
• High degree of creativity in problem-solving

REQUIRED LICENSES, CERTIFICATES, REGISTRATIONS: None