Regulatory Compliance Coordinator

WVU Medicine•Martinsburg, WV

About The Position

The Regulatory Compliance Coordinator assists with continual readiness for Joint Commission and CMS/OHFLAC surveys and oversees regulatory compliance activities and initiatives supporting effective clinical resource utilization and quality improvement. The role promotes interdisciplinary collaboration and patient-centered care and is also responsible for Emergency Preparedness. In the Compliance Officer capacity, the position monitors compliance with federal and state legal and regulatory provisions; provides education and training to professional and support staff and students under 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 officer adheres to the facility and WVUHS Code of Ethical Behavior, Corporate Ethics Plan, Corporate Compliance Program, and applicable handbook policies and procedures. The role leads regulatory readiness and performance-improvement work, including data collection, analysis, reporting, audits, survey preparation, responses to findings, and communication of accreditation status. It also supports safety and risk management investigations and directs planning, coordination, training, and exercises for the Emergency Management Program and Emergency Operations Plan.

Requirements

Bachelor's degree or higher, or a current Registered Nurse license issued by the state where services are 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 use Microsoft Word, Excel, Access, and other software to collect, analyze, and present data.
Demonstrated assertiveness, flexibility, effective interpersonal communication, diplomacy, written and verbal communication, negotiation, analysis, and research skills.
Ability to utilize community and system resources.

Nice To Haves

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

Responsibilities

Lead the development and implementation of regulatory activities and monitor indicators for assessing regulatory compliance.
Develop and implement ongoing data collection, analysis, and reporting mechanisms for regulatory indicators.
Establish mechanisms to ensure timely and accurate data reporting.
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 trends and assess medical staff and institutional compliance with Joint Commission standards and CMS conditions of participation.
Develop and submit reports to appropriate individuals and committees.
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 the Joint Commission.
Monitor required measures of success and submit them to the 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 completion of 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 internal and external event responses.
Plan, resource, and execute 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.
Monitor compliance with federal and state legal and regulatory provisions; provide education and training to staff and students under affiliation agreements; coordinate audit reviews; chair the hospital compliance committee; provide 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.