Job Summary
Coordinates the regulatory activities of the Hospitals and Clinics to meet the requirements of multiple regulating agencies for accreditation.
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Qualifications
Bachelor’s degree in a health-related field; four years of patient care experience; demonstrated knowledge of JCAHO and HCFA requirements; and demonstrated human relation and effective communication skills required.
Previous management experience is preferred.
This position is not responsible for providing care to patients.
Applicants must demonstrate the potential ability to perform the essential functions of the job as outlined in the position description.
Applicants must demonstrate the potential ability to perform the essential functions of the job as outlined in the position description.
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Disclaimer
This job description has been designed to indicate the general nature and level of work performed by employees within this
classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities
and qualifications required of employees assigned to the job.
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Essential Functions
- Researches and analyzes JCAHO, HCFA, State and other regulatory agency requirements and issues, and educates staff accordingly.
- Facilitates QI activities and improvement processes.
- Develops mock surveys and self-assessment tools in collaboration with operational managers and directors.
- Analyzes reports and data such as regulatory agency evaluations, self-assessments, and investigations, and develops summaries and recommended action plans.
- Coordinates and performs activities relative to the regulatory surveys.
- Responsible for obtaining the Hospital and Clinics licensures by completing the appropriate documentation.
- Participates in hospital meetings, committees, and teams.
- Ensures availability of current references of regulatory agency standards and communicates changes to management.
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Problem Solving
Effectively assists the hospitals and clinics in preparation for regulatory surveys by communicating all necessary information to the appropriate departments and recommending actions to maintain compliance. This position is the primary contact and expert regarding regulatory agency standards governing the hospital and clinics.
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FLSA
Exempt
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| Updated: STM, May 2000 |
Evaluated: December 2000 |
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Grade Update: DV, Feb. 2004 |
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