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Regulatory Compliance and Accreditation Specialist

1 month ago

Westminster, Colorado, United States LifeBridge Health Full time
Job Description

We are seeking a seasoned professional to fill the role of Regulatory Compliance and Accreditation Specialist at LifeBridge Health. As a key member of our team, you will be responsible for ensuring that our hospital maintains compliance with regulatory standards and accreditation requirements.

About the Role

The successful candidate will have a strong background in healthcare administration, regulatory compliance, and quality improvement. You will work closely with senior leadership and departmental teams to develop and implement initiatives that promote continuous readiness for accreditation surveys and regulatory reviews.

  • Develop and maintain a comprehensive understanding of regulatory requirements and accreditation standards;
  • Maintain databases, documents, and sources of information for quality initiatives, accreditation efforts, and regulatory mandates;
  • Collect, analyze, and track tracer and compliance data;
  • Coordinate and conduct tracers to proactively assess compliance with regulatory standards and readiness for surveys;
  • Serve as subject matter expert for regulatory and/or accreditation standards;
Responsibilities

Your key responsibilities will include:

  1. Organizing, managing, and facilitating programmatic initiatives related to maintaining Joint Commission (TJC) Hospital Accreditation & CMS Hospital Certification;
  2. Establishing and sustaining organization-wide processes and systems to maintain compliance with The Joint Commission (TJC) standards, Center for Medicare and Medicaid Services (CMS) Conditions of Participation, COMAR regulations, and State Agency - Office of Healthcare Quality (OHCQ) requirements;
  3. Maintaining a hospital-wide system to track and maintain accreditations, certifications, and designations for the hospital in collaboration with department leaders and program coordinators;
  4. Routinely reviewing and making recommendations for policies and procedures relevant to accreditation and certification;
  5. Serving as liaison to regulatory and accreditation bodies, providing documentation and information as required or requested on time;
  6. Providing regulatory planning support for initiatives related to the development and implementation of clinical and administrative programs throughout our hospital;
  7. Assisting with external regulatory agency reviews & on-site surveys as needed;
  8. Ensuring compliance with regulatory requirements including meeting deadlines for data submission and corrective action plan submissions;
  9. Promoting Regulatory Readiness: Fostering a culture of continuous regulatory and survey readiness through a variety of on-going regulatory readiness activities;
  10. Maintaining professional knowledge of regulatory requirements, routinely attending webinars and conferences to stay abreast of best practices and serving as a resource for interpretation of regulatory accreditation standards;
  11. Interpreting relevance of standards in relation to hospital policies and practices;
  12. Maintaining awareness of changes in regulatory standards and disseminating pertinent information to the respective leadership, key stakeholders, and staff;
  13. Conducting patient and system tracers in survey-able areas through observation of practice and the physical environment, by reviewing policies, procedures, documents, staff files, etc., and by conducting interviews;
  14. Actively partnering with the assigned LifeBridge Health Chapter Chairs and organizational leaders to proactively evaluate compliance with regulatory requirements and identify what PI efforts are being implemented to achieve compliance;
  15. Serving as a regulatory consultant and participating in improving organizational performance through improvement activities and process re-engineering;
  16. Providing orientation to regulatory requirements and the LifeBridge Regulatory Readiness program for new leaders and staff members;
  17. Supporting and routinely presenting at Regulatory Readiness & Accreditation Committee meetings and ad hoc workgroups created to address areas of non-compliance;
  18. Monitoring compliance with regulatory standards and organizational policies and procedures by monitoring tracer completion, results, and data;
  19. Coordinates and conducts tracers to proactively assess compliance with regulatory standards and readiness for surveys;
  20. Completes periodic compliance review by evaluating tracer data and scoring the TJC standards & EPs in collaboration with the identified TJC Chapter Chairs;
  21. Works with senior leaders and the leadership team (directors and managers) to create interdisciplinary teams that meet routinely to proactively evaluate compliance, identify improvement tactics, and collaborate to achieve continuous readiness;
  22. Responsible for assessing the organization's compliance status;
  23. Maintain databases, documents, and sources of information for quality initiatives, accreditation efforts, and regulatory mandates;
  24. Collects, analyzes, and tracks tracer and compliance data;
  25. Serves as system administrator for tracer software system utilized by the hospital to monitor and track compliance with regulatory standards;
  26. Maintains a system for organizing required documents;
  27. Facilitates open and closed medical record review audits to assist in determining compliance with regulatory requirements and internal policies;
  28. Disseminates the results of compliance audits/tracers and surveillance results as needed and as data is available;
  29. Tracks follow-up on identified non-compliance & support performance improvement efforts;
  30. Actively participates in the overall improvement and organizational performance;
  31. Maintains effective communication with Hospital executives, leadership, physicians, and staff regarding departmental compliance monitoring activities and progress of performance improvement related to regulatory readiness;
  32. Identifies, plans for, communicates, monitors and evaluates actions to comply with existing and new regulations, standards and accreditation requirements;
  33. Provides consultative support in development and implementation of action plans;
  34. Assists in the development of actions plans with all levels of organizational leadership serving as a regulatory consultant and subject matter expert;
  35. Provides education to staff and physicians;
  36. Educates staff on regulatory requirements, how to identify non-compliance, how to escalate concerns with non-compliance, and on problem-solving techniques for regaining and maintaining on-going compliance;
  37. Provides training and serves as a resource for compliance improvement, regulatory compliance orientation and continuing educational programs for providers, management, and staff;
  38. Develops educational tools and innovative ideas to promote learning regarding performance improvement, patient safety, and regulatory compliance;
Qualifications and Requirements

To be considered for this exciting opportunity, you will need to possess:

  • A Master's degree in Organizational Development, Healthcare Administration, or a related field;
  • A minimum of 5-7 years of experience in healthcare administration, quality improvement, or regulatory compliance;
  • Proficiency in managing databases, creating data reports, and interpreting statistical reports;
  • Frequent presentation skills;
  • A strong background in regulatory compliance and quality improvement principles;
  • Excellent analytical, problem-solving, and communication skills;
About LifeBridge Health

As one of the largest health care providers in Maryland, we strive to CARE BRAVELY for over 1 million patients annually. We offer a comprehensive benefits package, competitive salary, and opportunities for professional growth and development.