Job Description

Hours: Monday - Friday

No major holidays or weekends!

REGULATORY COMPLIANCE COORDINATOR I

Provides leadership and/or assistance with hospital-wide activities to evaluate and improve adherence to the Joint Commission accreditation standards, CMS Conditions of Participation, and MD State regulations in preparation for all surveys.

1. Assists with preparation and participates in organizational visits from accrediting agencies.
2. Participates in survey command center activities which may include but is not limited to: keeping track of and fulfilling surveyor requests for environmental logs, policies and procedures, employee files, contracts, etc., and responding to emails and phone calls.
3. Assists and participates in organization-wide Joint Commission readiness activities including tracers; monitoring and educating staff in regulatory compliance and hospital policy requirements.
4. Enters tracer data into accreditation tracking tool; reports from these data are provided to staff to use in staff education and improving compliance with Joint Commission standards and CMS Conditions of Participation (COPs).
5. Assists with internal regulatory assessments to evaluate and validate compliance with current standards set forth by various external regulatory agencies.

Qualifications

• Associate’s Degree in Nursing (ADN) is required. Bachelor's of Science in Nursing (BSN) preferred.
• Licensure Registered Nurse (RN) by the Maryland State Board of Nursing Examiners is required.
• 3 years of nursing (RN) experience required; regulatory, patient safety, or uality focus is preferred.
• Current experience in collecting and submitting externally reported quality data is preferred.

Additional Information

All your information will be kept confidential according to EEO guidelines.