Regulatory and Accreditation Program Coordinator
The Accreditation and Regulatory Program Coordinator serves as the resource on regulatory/accreditation and licensure standards and expectations for compliance. The coordinator designs and implements a systematic approach to ensure awareness and sustainability of regulatory and accrediting agency requirements throughout the organization, including implications of failures in compliance. The coordinator will guide the development of policy and guidelines as they relate to TMCH and compliance with regulatory and accreditation guidelines and assist in the interpretation of these policies.
Provides central expertise regarding accreditation and licensure standards. Identifies, plans, communicates, monitors and evaluates actions to comply with existing and new regulations, standards and accreditation requirements throughout TMC Healthcare.
Specific duties include timely analysis of regulatory materials, journals, and newsletters for implications on operations; development of working relationships with external agency representatives and key contacts to assist understanding of compliance requirements; and attendance at appropriate educational programs.
Provides coaching for organizational preparation and readiness for regulatory and accreditation surveys.
Implements a periodic organizational needs assessment for regulatory compliance including Intra-cycle Monitoring (ICM), using the Focused Standards Assessment (FSA) Tool required by The Joint Commission.
Identify areas of vulnerability and assist leaders in developing corrective action plans; also identify and communicate areas of success to celebrate and encourage promotion of best practices.
Review, assess, and work to revise relevant medical center policies and procedures and/or recommend and assist with the development of new policies and procedures to ensure compliance with regulatory, accreditation, and professional standards.
Serves as an additional liaison, with the Quality Director, to regulatory agencies and accreditation bodies.
Provides documentation and other information as required or requested on time to assure compliance for regulating and accreditation agencies. Maintain and organize all critical documentation support in compliance with requirements; oversee the development of delivery and follow-up documentation (i.e. reports, plans, appeals, measures, etc.).
Manage on-site and off-site visits to include scheduling, logistics and communication within the organization.
Provides consultation to all departments on the interpretation and application of TJC accreditation standards and Centers for Medicare and Medicaid Services (CMS) Conditions of Participation to maintain ongoing readiness.
Assist area leaders in the development of specific educational material to address areas of vulnerability for compliance with standards or unique requirements for special accreditations; assist the medical center in the review of all educational materials for regulatory or accreditation compliance to assure they reflect medical center practice and congruency with each other.
EDUCATION: Bachelor’s degree or an equivalent combination of relevant education and experience.
EXPERIENCE: Five (5) years healthcare experience, preferably in an acute care setting. A background in accreditation, data analysis, and/or case review is preferred.
LICENSURE OR CERTIFICATION: Active unrestricted RN license within the State of Arizona, or NLC preferred.