Texas
Fairbanks, Alaska
Mansfield, Ohio
Charleston, West Virginia
Posted: 17-Mar-23
Location: Albuquerque, New Mexico
Salary: Open
Internal Number: 2383
Department: Regulatory
FTE: 1.00
Full Time
Shift: Days
Position Summary:
Plan, implement, and continually monitor all aspects of accreditation, regulatory and hospital licensure compliance within UNM Hospital. Provide consultation to healthcare leadership on accreditation readiness. Establishes and monitors methods to maintain regulatory compliance. Coordinates with all departments to ensure compliance with state, federal and regulatory standards. Identifies opportunities for improvements based on evidence based practices in regulatory and accreditation compliance, analysis of internal and external compliance/risk assessments and findings from regulatory authorities. Ensure adherence to Hospitals and departmental policies and procedures. No patient care assignment.
Detailed responsibilities:
* PROJECTS - Serve as project facilitator for various task force committees to include coordinating, facilitating and overseeing project planning and development
* POLICIES - Participate in the development of goals, objectives, policies and procedures for assigned area(s); evaluate and analyze the efficiency and effectiveness of delivery methods and procedures
* BENCHMARKING - Consult and collaborate various benchmarking projects with Vizient or other nationally recognized benchmark studies, physician liaisons and nurse managers
* ANALYSIS - Provide baseline, benchmark and follow-up data/information analysis to facilitate process improvement; conduct and report on monitoring activities in assigned departments and areas
* LIAISON - Serve as a liaison for assigned area; coordinate activities in collaboration with other staff professionals, divisions, departments and organizations; may chair steering committees
* PROCESS IMPROVEMENT - Direct, manage, develop, and implement multiple strategic planning and process improvement initiatives
* RECORD REVIEWS - Conduct chart review; develop, prepare, present and disseminate clinical quality reports
* MEETINGS AND PROFESSIONAL DEVELOPMENT - Attend and participate in professional meetings and committees; stay abreast of new trends, innovations and regulatory oversight requirements
* PATIENT CENTERED MED - Adhere to and promote the core expectations of the Patient Centered Medical Home or Patient Centered Specialty Practice as applicable
* REGULATORY ASSESSMENT - Identify and recommend areas of improvement through data research, statistical analysis; prepare, present and disseminate information to professional individuals, groups and organizations
* REGULATORY AGENCIES - Develop and implement strategies that ensure the organization maintains a state of perpetual readiness for reviews by regulatory agencies and to achieve a level of quality and service that exceed regulatory requirements
* COMPLIANCE - Ensure compliance with all regulatory agencies governing health care delivery and the standards of accrediting bodies by continually monitoring the hospital's operations and its programs
Qualifications
Education:
Essential:
* Bachelor's Degree
Education specialization:
Essential:
* Related Discipline
Experience:
Essential:
3 years directly related experience
Nonessential:
Computer MS Office Suite experience
Credentials:
Physical Conditions:
Medium Work: Exerting 20 to 50 pounds of force occasionally, and/or 10 to 25 pounds of force frequently, and/or greater than negligible up to 10 pounds of force constantly to move objects. Physical Demand requirements are in excess of those for Light Work.
Working conditions:
Essential:
* No or min hazard, physical risk, office environment
* May be required to travel to various work sites
