Job Description
Purpose & Scope:
The individual in this position is responsible for ensuring compliance with healthcare regulations and standards within our organization as defined by accreditation and licensing organizations such as CMS, Department of Health, Department of Licensing and The Joint Commission. The individual will work closely with department heads, internal teams, and external stakeholders to develop and implement strategies that promote adherence to regulatory requirements and support the delivery of high-quality healthcare services.
Education:
Bachelors degree in Nursing, Pharmacy, other clinical field, or Public Health is required.
Masters degree in Nursing, Pharmacy, other clinical field, or Public Health is preferred.
Experience:
Five years experience with healthcare regulatory compliance, quality, patient safety or related experience is required.
Two years experience in data evaluation and analytics is required.
Certification/Licensure:
Certification in healthcare compliance (e.g., CHC, CHPC) preferred
Other Qualifications
In-depth knowledge of healthcare regulations, laws, and standards, including HIPAA, FDA regulations, CMS requirements, and other relevant guidelines.Strong knowledge of CMS Star Rating, Leapfrog, NHSN, NDNQI measures and requirements, including HEDIS, HCAHPS CAHPS, and other quality metrics.Experience in developing and implementing quality improvement initiatives in a healthcare setting.Excellent analytical skills, with the ability to interpret performance data and identify actionable insights.Strong ability to interpret complex regulatory requirements and develop practical compliance solutions.Excellent communication, negotiation, and interpersonal skills, with the ability to effectively collaborate with internal and external stakeholders.Demonstrated the ability to influence, including to motivate and inspire team members to achieve compliance goals.
Physical Requirements:
Administrative: The work environment characteristics described here are representative of those an employee may encounter while performing the essential function of the job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essentials functions: Repetitive movement of hands and fingers - typing and/or writing. Walking: moving about on foot to accomplish tasks, sometimes for long distances. Frequent standing, walking, stooping, kneeling or crouching. Reach with hands and arms. Frequent communications, verbal and written, and auditory acuity. Visually or otherwise identify, observe and assess. Cope with mental, emotional stress associated with this position. Operate Office machines properly and in accordance with Hospital safety standards. Perform light lifting (up to 15 pounds). Ability to work within deadlines with frequent interruptions. Ability to work in accordance with Hospital Safety Standards.
Working Conditions:
Patient Care: Works in well-lighted/ventilated office/clinical setting. Subject to frequent interruptions. Subject to long hours, changing shifts. May be required to work beyond normal working hours when requested to do so, e.g., overtime, on call. Routine occupational exposure to infectious diseases, blood borne pathogens, bodily fluids, hazardous chemicals, noxious odors, latex, and/or musculoskeletal injuries. The use of personal protective equipment (PPE) is needed for instances of exposure to blood, body fluids and infectious processes, and are supplied by the hospital. Involved with patients, family members, co-workers, and visitors under all conditions, e.g. hostile and/or emotionally upset, disoriented or combative.