- Serve as a resource for interpretation of regulatory, accreditation and disease-specific care certification standards (as applicable) to include CMS, State, and TJC for Marshall, Longview, and Ambulatory Clinics.
- Interpretation of relevance of standards in relation to hospital/department policies and practices.
- Performs concurrent and closed medical record review audits to assist in determining compliance with accreditation and regulatory requirements.
.* Conducts patient and system tracers in patient care areas through observation of practice.
- Collects, analyzes and reports data in support of continuous readiness activities.
- Disseminates the results of audits and surveillance results as needed.
- Assist in assuring accuracy and timeliness in submission of corrective action plans to internal stakeholders and external agencies.
- Designs and implements survey management plans
- Develops and delivers staff and leadership education related to regulatory and accreditation standards and processes.
- Facilitates monthly Accreditation Readiness Committee to include agenda planning, minutes, presentations as needed.
CPR required. CPHQ and/or HACP specialty certification or must obtain within 2 years.
Current RN license with the ability to practice in the state of Texas.
Graduate of a school of nursing required. Bachelor in Nursing/Science is preferred.
2 years' experience in quality or regulatory compliance to include at least 1 year responsible for compliance for JCAHO and/or other Accreditation agencies in an acute care setting preferred.
Ability to perform the essential functions of this position, with or without reasonable accommodation and without posing a direct threat to the health and safety of self or others. Ability to comply with all Good Shepherd policies and procedures that are job-related and consistent with business necessity. Ability to effectively communicate with patients and provide competent care as appropriate to the ages of patients served by this position.
Computer literacy is desired.