RN, Clinical Regulatory Compliance

Position 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

Key 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.
• Participates in the evaluation of compliance with laws, regulations and standards.
• Identifies and assesses risk as an integral part of the regulatory compliance review process.
• Manages risk through use and facilitation of risk reduction strategies.
• Provides guidance and utilizes quality improvement tools and techniques to address deficiencies.
• 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.
• Supports, facilitates and participates in departmental, affiliate, and system committees and project teams as assigned, such as Quality
Resource Meeting, Quality Council, Regulatory compliance meetings, quality improvement teams and workgroups.
• Participates in the patient safety program and other regulatory required programs as related to job functions.
• Functions as a change agent, utilizing skills in interpersonal relations and conflict resolution.
• Manages information effectively utilizing computer, statistical, research and data analysis skills.
• Formally represents affiliate with DNV, TJC, DOH (state and regional), OMH, IPRO, and OHSM and other regulatory agencies in
accordance with assigned duties.
• Is accountable to collaborate with others to ensure that necessary plans of action are completed and submitted to regulatory,
accreditation and/or standards organizations by indicated due dates.
• Works with department managers to monitor compliance with action plans submitted to regulatory/accreditation agencies.
• Provides leadership in assuring appropriate collaboration among service lines, departments and project teams to enhance patient safety,
clinical excellence and regulatory compliance.
• Assists in the completion of the annual DNV self-assessment and development of action plans for deficiencies prior to on site surveys as
applicable.
• Assists departments in resolution of deficiencies by providing strategies or guidance on strategies that would successfully meet the intent of the standard.
• Collaborates with direct supervisor to assess survey readiness of affiliates/departments/services and provides consultation where
indicated.
• Provides administrative and staff updates and education regarding any regulatory or standards changes.
• Collaborates with department directors/managers to resolve continued noncompliance with standards.
• Provides mentoring and coaching of care providers regarding aspects of on site survey inspections.
• Prepares and reports trends, measures, and outcomes to regulators and internal quality groups, as appropriate to job responsibilities.
• Participates in the orientation of new employees.
• Performs other clinical regulatory compliance duties as assigned.

Desired 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

Minimum Qualifications:
• Bachelor’s degree in nursing from an accredited educational organization required OR must obtain within three years upon date of hire. Master’s degree in nursing preferred.

Required Licensure/Certification:
•Registered Nurse licensure in New York State

EDUCATION:

LICENSES / CERTIFICATIONS: 

PHYSICAL REQUIREMENTS:

For disease specific care programs refer to the program specific requirements of the department for further specifications on experience and educational expectations, including continuing education requirements.

Any physical requirements reported by a prospective employee and/or employee’s physician or delegate will be considered for accommodations.

PAY RANGE:

The listed base pay range is a good faith representation of current potential base pay for a successful full time applicant. It may be modified in the future and eligible for additional pay components. Pay is determined by factors including experience, relevant qualifications, specialty, internal equity, location, and contracts.

Rochester Regional Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, creed, religion, sex (including pregnancy, childbirth, and related medical conditions), sexual orientation, gender identity or expression, national origin, age, disability, predisposing genetic characteristics, marital or familial status, military or veteran status, citizenship or immigration status, or any other characteristic protected by federal, state, or local law.