Compliance Coordinator

Lifepoint Health•Roaring Spring, PA

10d•Onsite

About The Position

We are seeking an experienced and relationship-driven Compliance Coordinator to join our growing health system. This is an exciting opportunity to play a key role in shaping the future of our medical staff and advancing access to high-quality care across our communities. The Compliance Coordinator is responsible to ensure system and processes are in compliance with all regulatory agencies including but not limited to The Joint Commission, PA Department of Health, Insurance Carriers, contracted fire protection engineering firms, and other regulatory agencies conducting surveys. This position supports the medical center’s commitment to comply with all federal, state, and local standards, with an emphasis on compliance. The Regulatory Compliance Coordinator develops and maintains the continuous readiness programs that contains all necessary elements to sustain regulatory compliance.

Requirements

Must be able to manage problems that are broad, complex and abstract, often involving company-wide issues, develop solutions using substantial creativity, resourcefulness, innovation, negotiation and diplomacy.
High School Diploma or GED

Nice To Haves

Associates Degree in Computer Science, Business Management or related field

Responsibilities

Supports exceptional clinical outcomes and patient safety using knowledge of all TJC, CMS and state licensure standards and/or regulations; uses tracer, audit and tracking tools to monitor all Conditions of Participation and DOH/TJC standards on a rotating basis throughout the year; identifies areas of high risk for more intense monitoring and intervention.
Maintains a regulatory scorecard that identifies metrics for compliance with the regulatory standards and provides reports as needed to the facility CEO, CNO, and PSO; takes an active role in resolving barriers to 100% achievement of the metrics.
Responds to inquiries by regulatory and accreditation bodies.
Conducts root-cause analyses on known DOH/TJC standards and develops action plans to address all causes in collaboration with facility leadership.
Monitors implementation of all regulatory plans of correction, reporting variances or deviation from the plan.
Reviews available quality and patient safety data to identify areas of high risk for standard deviation; develops action plans to correct deficiencies and ensures implementation and monitoring of those plans.
Works collaboratively with organizational development, infection prevention, pharmacy, plant operations, laboratory and other disciplines to educate leaders at every level on changes in standards; incorporates changes into the regulatory compliance program.
In coordination with the facility's quality team, monitors OFIs (Opportunities for Improvement) and sentinel event reports to focus on high risk areas that may negatively affect standards compliance.