The Regulatory/Accreditation RN role will perform quality process reviews of charts, audit data and investigate any irregularities. In addition, this role will provide analysis of data accreditation for compliance purposes.
Provide leadership to the organization in coordination with all things related to regulatory standards and elements of performance for CMS, IDPH, TJC and any other regulatory agencies.
Will co-lead on-site hospital surveys with TJC and in collaboration with other owners for Disease State Certification site surveys (stroke and diabetes).
Provide leadership in collecting accurate data, establishing systems for tracking/trending of data, analysis of accreditation data. Serves as expert in regulatory compliance.
Serve as expert in presentation of regulatory findings and changes in standards.
Provide leadership in Evidence Based Practice related to accreditation, helps to identify needed processes for concurrent monitoring of compliance and collaboratively works with chapter owners on oversight of current processes to achieve compliance.
Provide leadership and presentation of findings with Mock Surveys and ongoing departmental findings for medical staff meetings, and quality meetings and hospital department reports that include graphs, charts, scorecards, statistical presentation and power point. Co-lead the accreditation readiness committee meetings (ARRC).
Function as mentor or leader in multidisciplinary team improvements, understanding team building, customer satisfaction, organizational skills to support the teams such meeting deadlines and expertise in data management including accomplishment of outcomes
Function as expert in electronic and software programs such as Epic, Word, Excel and Power Point. Preferred knowledge and expertise of tracer software
Able to perform electronic chart reviews as needed for Disease State Certification Measures
Serves as a role model whose beliefs, attitudes and actions support organizational leadership and goals.
Demonstrates proficient leadership skills at the department level.
Demonstrates accountability for own professional practice, including progress toward achievement of annual goals
Required Job Qualifications:
Bachelor’s Degree in Nursing with least 3-5 Years Acute Care Quality Management with focus on accreditation readiness,
Knowledge of state and national regulations, standards, operating definitions for evidence-based measures.
Excellent data management skills, superior knowledge/execution of Microsoft Office and excellent skills in data analysis and presentation.
Ability to work independently with strong organizational and time management skills to meet competing deadlines, ability to make administrative/procedural decisions and excellent communication skills and demonstrating collaborative work ethics as a member of the quality team
Preferred Job Qualifications:
Master’s Degree in Nursing or Healthcare preferred
To further explore these opportunities with Rush Oak Park Hospital, apply online at: www.roph.org/jobs. Email: email@example.com
Internal Number: 40
About Rush Oak Park Hospital
Rush Oak Park Hospital has been providing exceptional health care in the community for more than a century. As a clinical partner of Rush University Medical Center, ROPH combines the convenience and personal touch of a community hospital with the technology and expertise of a major university medical center.