GENERAL SUMMARY/BASIC PURPOSE OF JOB:

Develops, facilitates and coordinates quality improvement initiatives as related to regulatory compliance

resulting in improved patient care, operations and patient experience. Collaborates with hospital staff on

initiatives to improve the integrity of the environment of care and emergency preparedness of the

organization. Supports the team with accreditation and regulatory compliance initiatives including the

Environment of Care Committee and Accreditation Committee for the System. The Regulatory

Compliance Specialist will write new and revise existing SHS policies and will assist SHS leadership with

writing departmental procedure, in addition to training all staff within the organization on the policy

program and ensuring leadership has trained staff on new and/or revised guidelines and requirements.

Regulatory Compliance Specialist will also chair and lead the Policy Committee meeting.

ESSENTIAL FUNCTIONS AND DUTIES:

• Directs survey readiness activities that support continuous compliance with

accreditation and governmental regulations, including voluntary, mandatory

and contractual reporting requirements.

• Develops, deploys and leads the chapter lead model for regulatory readiness

for the system.

• Develops, deploys and executes the survey response process to ensure a

dynamic and extraordinary positive experience for surveyors presenting to

survey the organization and the site leaders and frontline staff and providers

being surveyed.

• Maintains “expert” knowledge of standards related to accreditation and

regulatory bodies, i.e., The Joint Commission, CMS, IDPH, CARF, and HFAP.

• Develops, files, and executes plans of correction in follow up to surveys.
• Responsible for keeping abreast of current/changing regulatory reporting

requirements with potential to impact documentation practices and related

training.

• Other duties as assigned

JOB REQUIREMENTS

MINIMUM WORK EXPERIENCE:

2+ year’s healthcare related experience in policy, procedure, documentation and

technical writing or equivalent work experience. Experience in regulatory and survey readiness

and response activities required. Quality & Regulatory experience preferred.

KNOWLEDGE & SKILLS:

Computer skills, including mastery of Microsoft Office products, data analytic software and

modeling, electronic mail and the worldwide web/ internet. Ability to learn new systems

software. Self-motivated and continuous learning capability required.

Knowledge on ICD 10 coding with awareness of risk and mortality adjustment methodologies

Knowledgeable of CMS, AHRQ, CDS and other reportabe agencies clinical performance measures.

Demonstrated knowledge of facilitating and coordinating healthcare improvement projects with

previous quality improvement project experience.

Proven results driven improvement experience preferred

High-level analytic skill in the use of complex quality data in business/value development and

the display of findings is desired.

Excellent oral, written and interpersonal communication skills.

Ability to work independently.

High degree of creativity in problem-solving

REQUIRED LICENSES, CERTIFICATES, REGISTRATIONS:

None

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