Regulatory Compliance Coordinator

WVU Medicine•Martinsburg, WV

6d•Onsite

About The Position

The Regulatory Compliance Coordinator assists with continual readiness for Joint Commission and CMS/OHFLAC surveys, oversees regulatory compliance activities, and supports initiatives that improve clinical resource utilization and quality. The role promotes interdisciplinary collaboration and patient-centered care and is also responsible for Emergency Preparedness. Serving as Compliance Officer, the position monitors compliance with federal and state legal and regulatory requirements; provides education and training for professional and support staff and students covered by affiliation agreements; coordinates audit reviews; chairs the hospital compliance committee; provides quarterly reports to the WVUHS Chief Compliance Officer; and represents WVUHS compliance interests in state and regional activities. The Compliance Officer is responsible for adherence to the Code of Ethical Behavior, Corporate Ethics Plan, Corporate Compliance Program, and applicable facility and WVUHS policies and procedures. The role leads regulatory activities and data monitoring, supports performance improvement, and prepares the institution for accreditation and regulatory surveys. It also carries safety and risk management responsibilities, including working with staff, administration, and legal counsel on issues involving patients, visitors, staff, or the facility. Emergency Preparedness responsibilities include directing the Emergency Management Program and Emergency Operations Plan, coordinating training and exercises, and representing the hospital on preparedness committees.

Requirements

Bachelor's degree or higher, or a current Registered Nurse license issued by the state where services will be provided or a current multistate Registered Nurse license through the enhanced Nurse Licensure Compact (eNLC).
Five years of professional experience in a healthcare setting.
Computer literacy.
Ability to demonstrate assertiveness, flexibility, effective interpersonal communication, diplomacy, written and verbal communication, negotiation, and analysis and research methods.
Ability to use Microsoft Word, Excel, Access, and other software to collect, analyze, and present data.

Nice To Haves

Certified in Healthcare Compliance (CHC).
Certified Professional in Healthcare Quality through the National Association for Healthcare Quality.

Responsibilities

Lead development and implementation of regulatory activities and monitor indicators used to assess regulatory compliance.
Develop and implement ongoing collection, analysis, and reporting mechanisms for regulatory indicators.
Establish mechanisms for timely and accurate reporting of data.
Monitor appropriate criteria and report data for specific procedures and services.
Develop performance improvement initiatives throughout the institution.
Prepare the institution to meet Joint Commission standards and CMS conditions of participation.
Collect data through department survey audits, chart reviews, and staff interviews.
Analyze data for trends and for medical staff and institutional compliance with Joint Commission standards and CMS conditions of participation.
Develop and submit reports to appropriate individuals and committees within the organization.
Present quality initiative updates, reports, and education to faculty and staff.
Help develop policies, processes, and activities that support continuous readiness for Joint Commission and CMS.
Prepare institutional responses to Joint Commission and CMS findings.
Prepare and submit evidence of standards compliance to Joint Commission.
Monitor required measures of success and submit them to Joint Commission accurately and on time.
Update Senior Administration on accreditation status.
Prepare the institutional Annual Periodic Performance Evaluation.
Develop assignments for chapter leaders and ensure they complete required assignments.
Attest to the completion and accuracy of the annual periodic performance evaluation.
Work with staff, Administration, and/or legal counsel on issues involving patients, visitors, staff, or the facility; gather facts, investigate, and review medical records as needed, and share reports with Administration and the Board of Directors as necessary.
Direct planning, coordination, and updates for all aspects of the Emergency Management Program and Emergency Operations Plan, including responses to internal and external events.
Plan, resource, and conduct Emergency Operations Plan training and exercises in coordination with hospital staff.
Represent the hospital on local, state, and regional hospital preparedness and association committees as required.
As Compliance Officer, monitor federal and state regulatory compliance, provide education and training, coordinate audit reviews, chair the hospital compliance committee, submit quarterly reports to the WVUHS Chief Compliance Officer, and represent WVUHS compliance interests in state and regional activities.
Maintain adherence to the Code of Ethical Behavior, Corporate Ethics Plan, Corporate Compliance Program, and applicable facility and WVUHS policies and procedures.