Regulatory Specialist - Clinical Improvement, Mercy Cedar Rapids Job at Mercy Medical Center - Cedar Rapids
This position supports Mercy’s philosophy of patient centered care by planning, designing, implementing, monitoring and maintaining comprehensive quality and compliance programs. The Quality and Compliance Specialist will ensure services are provided in accordance with standards established by state and federal regulations and accreditation standards. Through collaboration with leadership and staff, will provide direct and support activities related to accreditation and regulatory affairs, performance improvement, and administrative policy review and development.
Job Duties
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Coordinates the hospital accreditation and regulatory survey activity and serves as liaison to the hospital accreditation organization.
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Coordinates and assures completion of proactive risk assessments/ risk reduction activities conducted in response to published alerts from accreditation organizations and regulatory agencies.
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Assists hospital leaders with policy development to assure compliance with standards and regulations.
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Works collaboratively across hospital departments and clinical disciplines to educate staff and providers regarding changes in standards.
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Reviews available quality and patient safety data to identify areas of high risk for standards deviation; working collaboratively with hospital leaders, develops action plans to correct deficiencies and ensures implementation and monitoring of those plans.
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Rounds on patients with medical diagnoses that make them high risk for standards compliance variation and reports finding to appropriate hospital leadership.
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Monitors implementation of hospital plans of correction, reporting variances or deviation from the plans to executive leadership.
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Maintains a regulatory scorecard that identifies metrics for compliance with applicable standards and reports routinely to the hospital’s leadership; takes an active role resolving barriers in order to achieve 100% of the metrics.
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Supports exceptional hospital clinical outcomes and patient safety using knowledge of applicable accreditation, federal, and state standards and/or regulations; uses tracer, audit and tracking tools to monitor regulatory compliance on a rotating basis throughout the year; identifies areas of high risk for more intense monitoring and intervention.
Department Specific Duties
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N/A
Knowledge, Skills and Abilities
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Strong computer skills (Outlook, PowerPoint, Excel, Word).
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Ability to work in a complex and matrixed organization with multiple and competing priorities.
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Ability to analyze complex data, identify trends, and collaboratively build action plans which proactively resolve risk factors.
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Ability to work with tracer management databases.
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Has knowledge of and maintains competencies with TJC, CMS, and State hospital standards and regulations.
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Strong organizational skills.
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Excellent interpersonal communication/ customer service skills required.
Professional Experience
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Minimum of 3 years clinical experience required.
Education
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Bachelor's degree required.
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Master's degree preferred.
Licensure, Certification, Registration
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Current RN license preferred.
Physical Demand Requirements
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Light: Exert up to 20 lbs. of force occasionally and/or up to 10 lbs. of force frequently
Location: Mercy Medical Center - Cedar Rapids · Clinical Improvement
Schedule: Full Time, Day, 0800-1630
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