Assists the Director in implementing and evaluating the Regulatory & Accreditation Affairs Program in order to ensure compliance with Medicare COPs, TJC chapter requirements, and all other relevant regulations related to healthcare governing and accrediting bodies. Facilitates maintenance of accreditation across all levels of the Parkland Health and Hospital System. Maintains health system survey readiness at all times. Serves as a resource and mentor to less experienced Regulatory & Accreditation Analysts and coordinates the department's orientation and training.
Must have a Bachelor's degree in the healthcare field.
Prefer Bachelor's degree in Nursing.
Prefer a Master's degree in a related field or Master's degree in Nursing.
Must have six years of professional experience in regulatory, compliance, healthcare or nursing.
Must have data analysis and interpretation experience.
Must have experience as a presenter, speaker, and facilitator of both large and small groups on simple to complex topics.
Must have experience with writing of correct responses to regulatory agencies.
Must obtain certification as a Certified Professional in Healthcare Quality (CPHQ) or Certified Joint Commission Professional (CJCP) within 24 months from placement in role.
The CJCP certification is highly preferred.
RNs Only: Must have current RN license or valid temporary permit with the Texas Board of Nursing; or, valid Compact RN license.
Skills or Special Abilities
Must demonstrate expertise in the accreditation standards of Centers for Medicaid & Medicare (CMS), Texas Department of Health & Human Services (TDSHS), and The Joint Commission (TJC).
Must demonstrate the ability to serve as an expert to others within the Regulatory & Accreditation department.
Must demonstrate the ability to serve as a lead worker to others with the Regulatory & Accreditation department.
Must demonstrate the ability to respond to regulatory inquiries and survey activities.
Must demonstrate the ability to prepare and respond to regulatory and accreditation surveys.
Must demonstrate the ability to lead the house wide tracer program.
Must demonstrate the ability to coordinate reporting to TJC, TDSHS, CMS and other regulatory bodies.
Must be able to develop the hospital¿s plan of correction as required by regulatory bodies.
Must be able to demonstrate excellent analytical skills and techniques.
Must be able to demonstrate ability to analyze and interpret data.
Must have written and presentation skills, and personal computer skills in MS Project, MS Word, Power Point, Access, and Excel software.
Must be able to communicate effectively with all levels of internal and external personnel.
Must have excellent interpersonal skills and be willing to communicate with all levels of the organization.
Must demonstrate an ability to quickly and effectively change priorities with a positive and energetic attitude.
1. Serves as a lead worker by providing guidance and expertise to other Regulatory & Accreditation Analysts to ensure effective and efficient operations of the department.
2. Coordinates the preparation for announced and unannounced regulatory survey activities to include communication and corrective action plans related to the survey activities.
3. Provides detailed written description of events in response to sentinel events, EMTALA or events which will be reviewed by leadership and provided to regulatory bodies.
4. Maintains knowledge of applicable rules, regulations, policies, laws, and guidelines that impact Parkland¿s healthcare licensing and accreditation. Develops effective internal controls designed to promote adherence with applicable laws, accreditation agency requirements, and federal, state, and private health plans. Seeks advice and guidance as necessary to ensure proper understanding.
5. Notifies executive leaders of regulatory updates by reviewing TJC, TDSHS, and CMS regulations, and assists with implementation within the appropriate department/committee agenda(s).
6. Acts in advisory capacity by reviewing regulatory committee minutes and proceedings, ensuring continuity, appropriate follow-up, and ultimate closure of identified quality issues. Collaborates with management responsible for licensing and accreditation in order to isolate deficiencies and to promote corrective actions.
7. Maintains a positive working relationship with management, hospitals, and employees, ensuring effective departmental operations. Serves on various interdisciplinary committees as assigned. Provides continuity and coordination for all CMS, TDSHS, and TJC activities as needed.
8. Takes advantage of educational opportunities and educates others as appropriate in order to interpret and implement compliance strategies and then measure the success. Stays abreast of the latest developments, advancements, and trends in the field of Regulatory & Accreditation by attending seminars/workshops, reading professional journals, and actively participating in professional organizations. Integrates knowledge gained into current work practices.
9. Educates Parkland staff on issues associated with Accreditation/Licensure standards as needed. Coordinates survey preparation and complaint investigations conducted by regulatory and/or accreditation agencies.
10. Develops a methodology for data collection and reporting of data associated with regulatory and accreditation standards to the Board of Managers and Performance Improvement committees.
11. Facilitates the implementation of necessary changes in practice, policy, and procedures to maintain compliance with changes in regulatory requirements.
12. Identifies ways to improve work processes and improve customer satisfaction. Makes recommendations to supervisor, implements, and monitors results as appropriate in support of the overall goals of the department and Parkland.
1. Identifies ways to improve work processes and improve customer satisfaction. Makes recommendations to supervisor, implements, and monitors results as appropriate in support of the overall goals of the department and Parkland.
2. Stays abreast of the latest developments, advancements, and trends in the field by attending seminars/workshops, reading professional journals, actively participating in professional organizations, and/or maintaining certification or licensure. Integrates knowledge gained into current work practices.
3. Maintains knowledge of applicable rules, regulations, policies, laws, and guidelines that impact the area. Develops effective internal controls designed to promote adherence with applicable laws, accreditation agency requirements, and federal, state, and private health plans. Seeks advice and guidance as needed to ensure proper understanding.
Parkland Health and Hospital System prohibits discrimination based on age (40 or over), race, color, religion, sex (including pregnancy), sexual orientation, gender identity, gender expression, genetic information, disability, national origin, marital status, political belief, or veteran status.
Nearest Major Market: Dallas
Nearest Secondary Market: Fort Worth
Job Segment: Nursing, Patient Care, Registered Nurse, Data Analyst, Medicare, Healthcare, Data