Risk Management and Regulatory Compliance Coordinator
Location: Orange City, Florida
Internal Number: 23041507
All the benefits and perks you need for you and your family:
-Benefits and Paid Days Off from Day One
-Student Loan Repayment Program
-Debt-free Education* (Certifications and Degrees without out-of-pocket tuition expense)
Our promise to you:
Joining AdventHealth is about being part of something bigger. It’s about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that together we are even better.
The community you’ll be caring for: 1055 SAXON BLVD, Orange City, FL 32763
The role you’ll contribute: The Risk Management & Regulatory Compliance Coordinator provides leadership for safety, accreditation and regulatory activities through relationship with hospital administration and leadership, medical staff leadership, physicians, nurses, and ancillary and allied health departments to improve knowledge and performance for hospital safety, performance improvement and quality initiatives. Assists in the oversight of department staff as directed by the Director and/or Quality Manager. Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all. Provides concurrent case reviews and recommendations to ensure that evidence based best practices are implemented timely.Responsible for independent coordination of program submissions in compliance with federal guidelines. Liaison for the medical staff physician Medical Review and OPPE/FPPE process. This position represents the Office of Clinical Effectiveness at medical staff committees, new hire orientation and hospital leadership meetings by providing accreditation, regulatory, quality and safety updates. Coordinates annual accreditation activities. Serves as the patient safety designee as needed. Responsible for planning, implementation & monitoring of interventions to ensure evidence-based practices are implemented and participates in and/or leads performance improvement committees as directed.Prepares reports and statistical analysis for medical staff and hospital leadership meetings.Routinely utilizes sensitivity and diplomacy in daily interactions with others as many deal with sensitive, confidential or controversial information. Adheres to and enforces the Florida Hospital Corporate Compliance Plan, the rules and regulations of all applicable local, state, and federal agencies, and the standards of applicable accrediting bodies.Ensures facilitation of the patient grievance process as required by state and federal statutes. Adheres to and enforces the Florida Hospital Corporate Compliance Plan, the rules and regulations of all applicable local, state, and federal agencies, and the standards of applicable accrediting bodies.
The value you’ll bring to the team
·Serves as a hospital content expert on performance improvement projects, accreditation and safety. Provides leadership and support regarding questions from staff, leaders and physicians on performance improvement, quality projects, regulatory and accreditation. Utilizes outside resources for complex questions to ensure correct communication and interpretation (i.e. TJC intranet, ECRI, QualityNet websites).
·Participates in collaboration with or as the designee for the Quality Director, on AHS quality initiatives and/or collaboratives. This may include but is not limited to: Glycemic management, Partnership for Patients/HIIN, AHRQ safety indicators as assigned. Assists with data management, performance improvement, medical record review and meeting organization to help ensure initiative success and goals are met. Utilizes appropriate PowerInsight (PI) reports to coordinate performance improvement and safety projects.
·Liaison for the medical staff physician Medical Review and OPPE/FPPE process. This position represents the Office of Clinical Effectiveness at medical staff committees, performance review councils, and hospital leadership meetings by providing regulatory, quality and safety updates as assigned.Responsible for ensuring all cases referred to Medical Review are dealt with according to hospital Medical Review policy and medical staff bylaws. This may include screening, reviewing with appropriate department chairman, preparing cases to be brought to committee, completing agenda/minutes for committee meeting, communicating committee decisions to involved medical staff providers and providing updates to Medical Executive Committee and hospital Executive Council. Maintains familiarity with medical staff bylaws as an internal content expert.
·Responsible for maintaining daily screening process for all inpatient admission throughout hospital. Utilizes appropriate PI reports as verification tool to ensure all patients with coded diagnosis for core measure conditions after discharge have all appropriate safety measures addressed. When discrepancy or variance is noted, responsible for notifying front line nurse, physician and/or leadership to ensure correction is made prior to discharge or chart completion deadline. Responsible for performing error checking and validation procedures in conjunction with Premier/Florida Hospital Association liaison prior to monthly submission. Responsible for completing all abstraction by AHS monthly and CMS quarterly deadlines.
·Plans, implements & monitors interventions to ensure evidence-based practices are implemented and participates in and/or leads performance improvement committees and teams. Leads special projects for the Chief Medical Officer, Quality Director and Quality Manager while using judgment for the level of discretion and confidentiality needed.
The expertise and experiences you’ll need to succeed:
·Bachelor’s degree OR 5 years’ clinical experience
·Minimum of 3 years healthcare experience
·Preparing and presenting professional presentations to executive leadership teams
·Accreditation activities and survey preparation
·Provider performance improvement activities
·Strong computer skills in Microsoft Office Suite (i.e., Word, Excel, Access, PowerPoint, Outlook)
·Excellent communication skills- written, oral and presentation - to build relationships with all departments, physicians and executive team
·Must possess presentation skills, as well as negotiation and advocacy skills when interacting with fellow members of the healthcare team as well as outside accrediting agencies, legal bodies, and other healthcare institutions. Internal and external contacts are often problem-driven
·Analytical ability to interpret data trends
·Acts independently and demonstrates organizational and problem-solving skills
·Bachelor’s degree in a healthcare related field
·Experience with regulatory, patient safety, Peer Review or OPPE process
·Healthcare related performance improvement or project management experience
·Proven ability in areas of leadership/ supervision, knowledge of regulatory aspects of healthcare, QA/QI principles, education and outcomes
·Facilitation of various PI methodologies (Six Sigma, Lean, PDSA, etc.)
·Six Sigma Performance Improvement Certification
·LEAN Performance Improvement Certification
·Team STEPPS Certification
·Certified Professional in Healthcare Risk Management (CPHRM)
·Certified Professional in-Patient Safety (CPPS)
·Certified Joint Commission Professional (CJCP)
·Certified Professional in Healthcare Quality (CPHQ)
At AdventHealth, Extending the Healing Ministry of Christ is our mission. It calls us to be His hands and feet in helping people feel whole. Our story is one of hope — one that strives to heal and restore the body, mind and spirit. Our more than 80,000 skilled and compassionate caregivers in hospitals, physician practices, outpatient clinics, urgent care centers, skilled nursing facilities, home health agencies and hospice centers are committed to providing individualized, wholistic care.