SUMMARY

Provides and supports regulatory, accreditation and certification activities to achieve and sustain ongoing compliance. Takes action to assure timely and complete preparation, support and follow-up to surveys, reviews and investigations. Represents the organization in interfaces with regulatory and accreditation agencies. Remains current with state and federal regulations and communicates that information within the organization. Works closely with leaders to develop and implement plans to meet new or revised regulations or standards. Collaborates with Performance Improvement and Patient Safety personnel, as well as affiliate and department leaders to promote and maintain compliance.

STATUS: Full Time

DEPARTMENT: Ambulatory

SCHEDULE: Monday-Friday, Days

ATTRIBUTES

• Experience working with regulatory and accreditation systems (eg. DOH, NYPORTS, TJC, IPRO, OMH).

• Experience in large group presentation and facilitation.

• Experience with data analysis and QI/PI preferred.

• Working knowledge of computer software including Microsoft Word, Excel, Power Point and Outlook.

• Strong communication, organizational, and interpersonal skills

• Registered Nurse licensure in New York state

RESPONSIBILITIES

• Develops and maintains competence in state and federal health care regulations, DNV and TJC accreditation standards as applicable.

• Collaborates in the development and implementation of affiliate/departmental/service/unit level regulatory and/or accreditation plans, programs, and reports.

• Identifies and assesses risk as an integral part of the regulatory compliance review process.

• Serves as a resource to staff for interpretation of regulations and standards. Researches and provides accurate interpretations and provides or arranges for education when indicated.

• Disseminates regulatory information and makes appropriate referrals to department directors/managers and/or Senior Leaders regarding regulatory, safety and risk management issues.

• Formally represents affiliate with DNV, TJC, DOH (state and regional), OMH, IPRO, and OHSM and other regulatory agencies in accordance with assigned duties.

• Assists in the completion of the annual DNV self-assessment and development of action plans for deficiencies prior to on site surveys as applicable.

• Participates in the orientation of new employees.

EDUCATION LICENSES/CERTIFICATIONS BLS - Basic Life Support - American Heart Association (AHA); RN - Registered Nurse - New York State Education Department (NYSED) Rochester Regional Health is an Equal Opportunity / Affirmative Action Employer. Minority/Female/Disability/Veteran PHYSICAL REQUIREMENTS : M - Medium Work - Exerting 20 to 50 pounds of force occasionally, and/or 10 to 25 pounds of force frequently, and/or greater than negligible up to 10 pounds of force constantly to move objects; Requires frequent walking, standing or squatting.