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Regulatory Compliance Specialist
2 months ago
A Regulatory Accreditation Specialist plays a vital role in ensuring delivery of high-quality healthcare services by performing audit activities across the healthcare system. Clinical processes and behaviors important to patient safety, regulatory compliance and quality of care are audited for current adherence of guidelines as well as successful implementation of process change. The Regulatory Accreditation Specialist will report to Accreditation and Regulatory Management leadership. Responsible for performing job duties in accordance with mission, vision and values with Tampa General Hospital.
Key Responsibilities:- Data Collection and Analysis: Collect relevant data by reviewing patient records, conducting interviews, and observing clinical practices within patient care areas of the system.
- Tracer Activities: Perform tracers, as directed by leadership for continuous accreditation readiness.
- Process Improvement: Monitor the effectiveness of implemented changes to ensure desired improvements are achieved in response to action planning and formal quality improvement work.
- Data Management: Creates and distributes data collection tools with data elements that can be collated, trended.
- Training and Development: Direct and train users on tool with acceptable inter-rater reliability.
- Data Dissemination: Manage data collection, aggregation, and dissemination as directed by leadership.
- Audit and Compliance: Utilize auditing platforms as to collect and organize findings, utilizing standard reporting tools to assure valid data that is informative and meets standards set for measurement.
- Collaboration and Communication: Collaborate with performance improvement, patient safety, infection prevention and all clinical teams to assure audit tools are complete and appropriate data governance has been followed.
- Regulatory Compliance: Participate in audits, inspections and activities associated with regulatory bodies or accreditation agencies.
- Expertise and Knowledge: Maintain expertise in quality, safety and regulatory indicators and specifications as well as sources of internal measurement and implement new requirements in such measurements.
- Experience: 3 to 5 years experience in a hospital or healthcare related setting with demonstrated experience with The Joint Commission (TJC) and other regulatory agencies or certification survey processes preferred.
- Education: BSN or Bachelor's degree in related field.
- Skills: 2 years experience in quality, risk or regulatory compliance required. Experience with related tools including computer programs such as Word & Excel required.
