Regulatory Compliance Coordinator I, RN License

University of Maryland Medical System•Baltimore, MD

About The Position

Under limited supervision, the Regulatory Compliance Coordinator I ensures organizational compliance with quality measures and other performance indicators required by regulatory and accrediting entities. The role contributes to establishing goals, objectives, and performance standards, and supports compliance with UMMC policies, quality standards, Joint Commission requirements, CMS requirements, and DHMH regulations and codes. The coordinator supports hospital-wide readiness, assessments, surveys, and reporting related to regulatory standards. This includes coordinating survey preparation and command-center activities, conducting tracers and internal assessments, abstracting and validating data, monitoring corrective action plans, and working with providers and staff on quality improvement and clinical documentation. The position also analyzes performance data, maintains staff awareness of documentation changes, and supports patient-safety initiatives.

Requirements

Associate’s Degree in Nursing is required.
Licensure by the Maryland State Board of Nursing Examiners is required.
Three years of nursing experience is required.
Demonstrated expertise in using data, validating data, and producing reports.
Ability to navigate computer applications to abstract needed data.
Ability to navigate external databases that publicly report quality data and retrieve or enter data.
Highly effective oral and written communication skills for working with hospital personnel, administrators, clinical staff, and outside agencies.
Self-motivated and an independent thinker.
Working knowledge of Microsoft Word, Excel, and PowerPoint.

Nice To Haves

Bachelor of Science in Nursing (BSN).
Regulatory, patient-safety, or quality-focused experience.
Current experience collecting and submitting externally reported quality data.
Current and comprehensive knowledge of the methodology and definitions used for core-measure data abstraction.

Responsibilities

Support hospital-wide activities to evaluate and improve compliance with Joint Commission accreditation standards, CMS Conditions of Participation, and Maryland State regulations in preparation for surveys.
Assist with preparation for and participation in visits from accrediting agencies.
Participate in survey command-center activities, including tracking and fulfilling surveyor requests for environmental logs, policies and procedures, employee files, contracts, and other materials, and responding to emails and phone calls.
Support organization-wide Joint Commission readiness activities, including tracers, and monitor and educate staff on regulatory compliance and hospital policy requirements.
Enter tracer data into the accreditation tracking tool and provide resulting reports to staff for education and compliance improvement.
Assist with internal regulatory assessments to evaluate and validate compliance with current external regulatory standards.
Abstract data to evaluate medical-center compliance with Joint Commission standards and CMS Conditions of Participation.
Monitor progress on action plans responding to external audits and surveys through concurrent and retrospective chart review.
Work with providers to monitor and promote quality improvement activities related to regulatory requirements and clinical documentation in the medical record.
Participate in Epic UDCs to ensure documentation elements are properly embedded in the EHR to meet regulatory standards and Conditions of Participation.
May assist with State and Federal Quality projects to obtain comparative data on quality and regulatory indicators.
Attend assigned hospital-based committee meetings.
Plan, organize, and direct activities focused on hospital compliance with Joint Commission, CMS, and other external reporting entities.
Ensure compliance with established quality measures.
Assure data quality, reliability, and validity; compile and enter data into designated databases.
May serve as System steward to validate data submissions to the Joint Commission and CMS.
Abstract EHR data to assess compliance with Joint Commission and CMS guidelines.
Analyze data to identify opportunities to improve organizational performance.
Keep staff up to date on changes in documentation requirements; provide regular feedback and support for quality and safety activities.
May facilitate development of department-level quality initiatives.
Promote patient safety through job performance and participation in hospital-, department-, or unit-based initiatives.
Take action to correct observed risks to patient safety; report adverse events and near misses to appropriate management; and identify and communicate potential risks in processes, procedures, and devices to those responsible.