Regulatory Compliance Coordinator

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Primary responsibility is to assist in the continual readiness for Joint Commission and CMS/OHFLAC surveys. Oversees activities related regulatory compliance, and other initiatives that lead to effective clinical resource utilization and improvements in quality. Promotes interdisciplinary collaboration and teamwork to promote excellence in patient centered care. This position also has responsibility for Emergency Preparedness.

Compliance Officer: Responsible for monitoring compliance with federal and state legal and regulatory provisions; education and training for professional and support staff; education for students under affiliation agreements; coordination of audit reviews; serves as chairperson for the hospital compliance committee; supplies quarterly report to the WVUHS Chief Compliance Officer and participates in state and regional activities, representing the compliance interests of WVUHS. As Compliance Officer, the officer maintains strict adherence to, and compliance with, the Code of Ethical Behavior, Corporate Ethics Plan, Corporate Compliance Program and all applicable Handbook Policies/ Procedures of the facility and WVUHS.

MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Bachelor's degree or higher 

OR  

Current Registered Nurse license issued by the state in which services will be provided or current multi-state Registered Nurse license through the enhanced Nurse Licensure Compact (eNLC). 

EXPERIENCE:

1. Five (5) years of professional experience in regulatory compliance, accreditation, or quality improvement.

PREFERRED QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Certified in Healthcare Compliance (CHC) Certification

2. Certified Professional in Healthcare Quality through National Association for Healthcare Quality 

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position.  They are not intended to be constructed as an all-inclusive list of all responsibilities and duties.  Other duties may be assigned.

1. Leads in the development and implementation of regulatory activities and monitors indicators for assessment of regulatory compliance.

2. Develops and implements mechanisms for ongoing data collection, analysis, and reporting of regulatory indicators

3. Initiates mechanisms to ensure timely and accurate reporting of data.

4. Monitors appropriate criteria and reports the data for specific procedures and services.

5. Develops performance improvement initiatives throughout the institution.

6. Prepares the institution to successfully meet Joint Commission standards and Centers for Medicare and Medicaid Services (CMS) conditions of participation.

7. Collects data through survey audits of departments, chart review, and staff interviews.

8. Analyzes data for trends and for medical staff and institutional compliance with Joint Commission standards and CMS conditions of participation.

9. Develops and submits reports for appropriate individuals and committees within the organization.

10. Interacts with faculty and staff to present quality initiative updates, reports, and education.

11. Assists in the development of appropriate policies, processes, and activities to support continuous readiness for Joint Commission and Centers for Medicare and Medicaid Services.

12. Prepares the institutional response to Joint Commission and CMS findings. 

13. Prepares and submits evidence of standards compliance to Joint Commission.

14. Ensures timely and accurate monitoring of required measures of success. Submits measure of success to Joint Commission.

15. Updates Senior Administration as to the current status of accreditation.

16. Prepares institutional Annual Periodic Performance Evaluation.

17. Develops assignments for chapter leaders and ensures chapter leaders complete required assignments.

18. Upon completion of annual period performance evaluation, attests to completion and accuracy.

19. Safety & Risk Management duties: Works closely with staff, Administration and/or legal counsel in the event of a issue which arises involving patients, visitors, staff or the facility.  This may result in fact gathering, investigation, review of medical records etc.  Reports, as necessary, will be shared with Administration and the Board of Directors.

20. Emergency Preparedness duties: Directs the planning, coordination and updates for all aspects of the Emergency Management Program and Emergency Operations Plan (EOP) including both internal and external event responses.  Plan, resource and execute all EOP training and exercise events in support of hospital preparedness while coordinating across the hospital staff. Serves as the Hospital representative to local, state and regional hospital preparedness and association committees as required.

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Frequent walking, standing, stooping, kneeling, reaching, pushing, pulling, lifting, grasping are necessary body movements utilized in performing duties through the work shift.

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Office and hospital setting.

SKILLS AND ABILITIES:

1. Must have computer literacy.

2. Demonstrates assertiveness.

3. Utilizes community and system resources.

4. Must be flexible.

5. Demonstrates effective interpersonal communication.

6. Demonstrates diplomacy.

7. Demonstrates written and verbal skills.

8. Demonstrates negotiation skills.

9. Demonstrates analysis and research methods.

10. Must be able to use Microsoft Word, Excel, Access and other software to collect, analyze, and present data.

Additional Job Description:

Scheduled Weekly Hours:

40

Shift:

Exempt/Non-Exempt:

United States of America (Exempt)

Company:

BMC Berkeley Medical Center

Cost Center:

609 UH Risk Management

Address:

121 Administrative DriveMartinsburgWest Virginia

Equal Opportunity Employer

West Virginia University Health System and its subsidiaries (collectively "WVUHS") is an equal opportunity employer and complies with all applicable federal, state, and local fair employment practices laws. WVUHS strictly prohibits and does not tolerate discrimination against employees, applicants, or any other covered persons because of race, color, religion, creed, national origin or ancestry, ethnicity, sex (including gender, pregnancy, sexual orientation, and gender identity), age, physical or mental disability, citizenship, past, current, or prospective service in the uniformed services, genetic information, or any other characteristic protected under applicable federal, state, or local law. All WVUHS employees, other workers, and representatives are prohibited from engaging in unlawful discrimination. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, training, promotion, discipline, compensation, benefits, and termination of employment.