Accreditation Regulatory Risk Management Specialist

4 weeks ago

Boston, United Kingdom crescentiasolutions Full time

MustHaves

Bachelors in nursingRegistered Nurse MassachusettsRequires at least 5 years of direct clinical care.Minimum of 1 year in accreditation regulatory and riskmanagement.

NiceToHaves

CPHRM Certification Preferred

JobDescription

POSITIONSUMMARY:

The AccreditationRegulatory and Risk Management Specialist:

leads efforts to ensure continual organizationalcompliance and ongoing readiness with clinical quality and patientsafety standards and regulations required by The Joint CommissionMassachusetts Department of Public Health/Mental Health and Centrefor Medicare and Medicaid Services. In this role the Managerproactively plans implements coordinates and continually improvesour clients efforts related to compliance accreditation andlicensure requirements and participates in thedevelopment implementation and coordination of a highly visibleproactive institutionwide program to maximize the safety ofservices delivered to BMC patients. The Specialist responds topatient harm events learns from individual cases identifies risktrends and actively educates leaders administration clinicians andstaff regarding methods to maximize patient safety andsimultaneously reduce professional liability claims.

Position: AccreditationRegulatory and Risk Management Specialist (Brockton)

Department: Brockton

Schedule: Full Time

ESSENTIAL RESPONSIBILITIES /DUTIES:

Accreditation/ RegulatoryResponsibilities

  • Serves as theorganizational expert for The Joint Commission (TJC) Department ofPublic Health (DPH) Department of Mental Health (DMH) Centres forMedicare and Medicaid Services (CMS) standards regulations andconditions of participation.
  • Responsible forthe interpretation and communication of regulatory and licensingrequirements throughout the organization.
  • Provides education and consultation to administrative andclinical leadership staff and faculty throughout BMC regarding therequirements of accreditation and regulatoryorganizations.
  • Provides guidance andassistance to departments sections units and programs regardingimprovements needed to ensure compliance with requirements of TJCDPH DMH and CMS.
  • Facilitates development oftools policies and procedures and learning aids to promotecompliance with standards.
  • Provides timelycommunication regarding new and revised TJC CMS DPH DMH standardsand interpretations to administrative and clinical leadership staffand faculty.
  • Works closely and buildseffective working relationships with accreditation and regulatoryagencies i.e. The Joint Commission DPH DMH and CMS.
  • Responsible for all aspects of the plan to ensurecontinual readiness with the clinical regulatory and accreditationrequirements of the TJC DPH DMH and CMS.
  • Thisincludes but is not limited to: Development coordination andimplementation of the continual readiness plan; Ongoing assessmentof the continual readiness plan; identification of neededimprovements; and preparation and implementation of plans toachieve needed improvements
  • Organizationaldepartment section unit and program assessments and identificationof risk
  • Plan and scheduling readiness mocksurveys
  • All ongoing communication withregulatory agencies regarding survey and readinessactivities
  • Development of remedial actionplans
  • Responding to agency requests forrevision and corrective action plans
  • Responsible for communication of the continuous readinessplan to leadership and key groups throughout BMC. Responsible forensuring preparation of reports assessing institutional departmentsection program and unit compliance with accreditation andregulatory requirements. Ensure that administrative and clinicalleadership are continuously aware of BMC readiness for TJC DPH DMHand CMS surveys including description of specific issues that needimprovement. Leads a coordinated response to unannounced externalaccrediting or regulatory agency visits such as TJC DPH DMH or CMS.Serves as a member on committees as deemed appropriate.

Risk ManagementResponsibilities

Investigates and analyses actual and potentialpatient/visitor safety events (nearmisses) for improvementopportunities and for the potential for legal action with coachingto increasing independence. Activities includebut are not limited to chart review staff/provider interviewspolicy review best practice research and observationactivities. Utilizes an online incidentreporting system for tracking patient safety events. Participates in activities to use this database toidentify trends and opportunities to improve patientsafety. Facilitates organization andoperationalization of root cause analysis activities on assignedcases. Participates in the on call system toprovide immediate consultation recommendations and mitigation tohospital staff in responding to adverse events. Participates in followup action plans required tominimize patient safety risks. Preparesreports to external regulatory agencies with increasingindependence as assigned. Activelycollaborates with Quality and Patient Safety staff to identify andmitigate local and organizational trends that impact patient safetyand to support implementation of safer processes and systems ofcare. Actively collaborates with ClaimsDepartment to assist BMC efforts to minimize legal/financialliability. Actively participates in clinicalcase review and case learning committees.Facilitates committee operations as assigned.Help to ensures compliance with various codes laws rulesand regulations concerning patient care including those mandated bystate federal agencies and accreditation standards.Demonstrates understanding legislative and regulatoryactivities related to patient safety and health care riskmanagement. Assists in the developmentmaintenance and revision of policies and procedures to improvepatient safety and minimize loss exposure.Ensures policies and procedures meet regulatory criteriaand are communicated to employees. Developsand presents educational sessions on patient safety andprofessional liability risk reduction to physicians andemployees. Assists clinical chairs anddepartment chiefs to design patient safety and risk managementprograms specific to their individual areas.Periodically reports on risk management matters andprepare reports for various committees and boards. Responsible for ensuring that all information necessaryto prepare for the defence of claims is collected and properlymaintained in a timely manner including the preparation of reportsof investigation.

(The abovestatements in this job description are intended to depict thegeneral nature and level of work assigned to the employee(s) inthis job. The above is not intended to represent an exhaustive listof accountable duties and responsibilities required).

JOBREQUIREMENTS

EDUCATION:

BachelorsDegree in nursing required

Graduate degree(Masters or Doctorate) preferred

CERTIFICATES LICENSES REGISTRATIONSREQUIRED:

Registered Nursewith CPHRM preferred

EXPERIENCE:

Requires at least 5 years of direct clinical care. Minimumof 1 year in accreditation regulatory and riskmanagement.

KNOWLEDGE ANDSKILLS:

Must haveinterpersonal skills necessary to deal effectively with aadministrative and clinical leadership staff Clinical Chairpersonsand other healthcare professionals Ability toeffectively interview individuals and groups from diverseprofessional backgrounds Maintain strictnessconfidentiality of information Ability tocollect event information and organize into a coherentnarrative Highly selfmotivated. Ability tomanage multiple projects simultaneously and adhere to workdeadlines. Ability to inspire trust and besomeone who provides support and assistanceExcellent verbal and written communicationskills. Excellent presentation skill includingability to speak before large audiences and prepare and providePower Point presentations. Excellent computerskills including Microsoft Office; ability to learn new computerapplications such as adverse event reporting software.Ability to develop effective relationships with a broadarray of people from diverse backgrounds.Strong interpersonal skills: ability to establishsupportive collegial relationships. Superiororganizational skills to manage a large volume of incoming datainformation reports etc. in paper and electronicformats. Ability to create and deliverappealing and compelling presentations to a variety of audiencesincluding clinicians staff faculty administration and governancegroups. Excellent written and verbalcommunication skills. Demonstrated skill inchange management and quality improvement.Knowledge of clinical terminology.Strong computer skills including Microsoft OfficeplatformWord Access Excel Email. Web/Internet.Ability to learn and effectively use computer softwaresuch as electronic health records and data entry.Excellent English communication skills (oral andwritten).

Info aboutposition

Background

Level:MidLevel

Vacancies:1

Travel Required: Travel notrequired

Visa Support: Novisa sponsorships supported

Location(s)

Country:United States of America

City: Boston

State: MA

Postal Code:02118

SigningBonus: No

RelocationPackage: None

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