Job Description

RN Regulatory and Accreditation Program Coordinator
Job CategoryNursing
ScheduleFull time
Shift1 - Day Shift

SUMMARY:

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.

 

ESSENTIAL FUNCTIONS:

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.

Adheres to TMC organizational and department-specific safety, confidentiality, values, policies and standards.

Performs related duties as assigned.

 

MINIMUM QUALIFICATIONS

EDUCATION:  Bachelor’s degree from a qualified, nationally-accredited nursing program, or an equivalent combination of relevant education and experience.

EXPERIENCE:  Five (5) years RN nursing 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.

 

KNOWLEDGE, SKILLS AND ABILITIES

  • Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations.

  • Ability to define problems, collect data, establish facts, and draw valid conclusions.

  • Ability to interpret an extensive variety of technical instructions in mathematical or diagram form and deal with several abstract and concrete variables.

  • Ability to provide clinical review of care processes.

  • Ability to navigate an Electronic Health Record.

  • Knowledge of regulatory quality requirements.

  • Skill in meeting facilitation.

  • Skill in both written and oral communications.

  • Ability to effectively present information and respond to inquiries or complaints from employees, physicians and/or their representatives.

  • Skill in the use of computer applications, and statistical analysis using a variety of tools such as EXCEL, Power Point, etc.

  • Ability to analyze complex situations and recommend action plans.

  • Ability to analyze clinical data efficiently and work with statistical concepts.

Application Instructions

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