Regulatory Readiness Coordinator

Job ID: J126093
Company: West Penn Allegheny Health System
Location: Pittsburgh, PA, United States
Facility: Allegheny General Hospital
Full/Part Time: Full time
Job Type: Regular
Posted at: Jun 29, 2018

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Description

GENERAL OVERVIEW:

Oversees and coordinates all activities related to maintaining organizational compliance with external regulatory and accreditation agency standards. Ensures that the hospital is in a state of continuous readiness for visits/surveys/investigations from external agencies (e.g., PA DOH, TJC, CMS) through proactive risk assessment and mitigation efforts. Ensure that policies and procedures are consistent with regulations, guidelines and accreditation standards and that compliance is sustained.

ESSENTIAL RESPONSIBILITIES:

  • Coordinates all activities related to maintaining organization compliance with external regulatory and accrediting agency standards. (20%)
  • Ensures that the hospital is in a state of continuous readiness for visits/surveys/investigation from external agencies such as the PA DOH and the Joint Commission. (20%)
  • Serves as organization liaison with The Joint Commission, PA DOH and other regulatory and accreditation organizations and agencies and serves as the organization point person during on-site surveys and investigations. Maintains the integrity and security of the Joint Commission extranet site. Oversight of regulatory education to staff and physicians.(20%)
  • Leads and assists with the hospital's response to survey findings and inquiries. (10%)
  • Identifies and facilitates resolution of system problems that impede regulatory compliance. (10%)
  • Develops policies, procedures, standards of care and clinical guidelines in collaboration with multidisciplinary groups consistent with regulatory and accreditation standards, including national patient safety goals and core measures. Coordinates the annual review of policies and procedures to ensure integration and alignment with regulatory and accreditation standards. Participates in and supports the AHN Policy Initiative developing consistent policies and procedures that reflect best practice in order to enhance quality, safety and regulatory compliance. (15%)
  • Responsible for ORYX and Core Measure performance measures, occurrence reporting information from State and Federal sources and current literature. Facilitates the completion of regulatory and accreditation applications, surveys and questionnaires. (5%)

QUALIFICATIONS:

Minimum

  • Bachelor's degree in nursing, business administration, healthcare administration or related field
  • 3 years experience
  • Successful coordination/participation in a hospital regulatory survey within the past 3 years
  • Three or more years developing improvement plans, implementing solutions, leading cross functional/matrix work teams

Preferred

  • Master's degree in Nursing, Health Administration or related field
  • LSS Green Belt or Lean Certified
  • CJCP or CPHQ certification

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
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