*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.
- Other Skills/Competencies
- 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 Skills
- Computer literacy is desired.