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Tucson Medical Center · 11 hours ago

RN Regulatory Program Coordinator

Tucson, AZ

Full-time

Onsite

Senior Level

5+ years exp

Tucson Medical Center is seeking a Regulatory Program Coordinator to serve as the expert resource on regulatory and accreditation standards. The role involves designing and implementing compliance strategies, providing leadership for regulatory surveys, and developing educational materials to ensure adherence to standards.

Health Care

Responsibilities

Provides central expertise regarding accreditation and licensure standards. Identify, plan for, communicate, monitor, and evaluate actions to comply with existing and new regulations, standards and accreditation requirements throughout the organization. Specific duties include timely analysis of regulatory materials, journals, and newsletters for implications on operations; development of working relationships with external agency representatives and key contacts to assist understanding of TMC compliance requirements; and attendance at appropriate educational programs

Provides leadership for organizational preparation and readiness for regulatory and accreditation surveys

Implements a periodic organizational needs assessment for regulatory compliance including Intra-cycle Monitoring (ICM), using the Focused Standards Assessment (FSA) Tool required by The Joint Commission

Identify areas of vulnerability and assist area leaders in developing corrective action plans; also identify and communicate areas of success to celebrate and encourage promotion of best practices

Review, assess, and work to revise relevant medical center policies and procedures and/or recommend and assist with the development of new policies and procedures to ensure compliance with regulatory, accreditation, and professional standards

Serves as an additional liaison, with the Quality Director, to regulatory agencies and accreditation bodies

Provides documentation and other information as required or requested on time to assure compliance for regulating and accreditation agencies. Maintain and organize all critical documentation support in compliance with requirements; oversee the development of delivery and follow-up documentation (i.e. reports, plans, appeals, measures, etc.)

Manage all agency site visits to include scheduling, logistics and communication within the organization

Provides consultation to all departments on the interpretation and application of TJC accreditation standards and Centers for Medicare and Medicaid Services (CMS) Conditions of Participation to maintain ongoing readiness

Development of mandatory educational material to meet periodic requirements

Assist area leaders in the development of specific educational material to address areas of vulnerability for compliance with standards or unique requirements for special accreditations; assist the medical center in the review of all educational materials for regulatory or accreditation compliance to assure they reflect medical center practice and congruency with each other

Adheres to and supports team members in exhibiting TMCH values of integrity, community, compassion, and dedication

Adheres to TMCH organizational and department-specific safety and confidentiality policies and standards

Performs related duties as assigned

Qualification

Regulatory compliance knowledgeAccreditation process knowledgeSurvey preparation skillsMock regulatory surveysReport preparation skillsTrainingEducationWritten communicationOral communication