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All the benefits and perks you need for you and your family:

• Benefits from Day One

• Paid Days Off from Day One

• Career Development

Our promise to you:

Joining AdventHealth is about being part of something bigger. It’s about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that together we are even better.

Schedule: Full Time

Shift : Day

The community you’ll be caring for:

AdventHealth Waterman

1000 Waterman Way, Tavares, 32778

The role you’ll contribute:

The Risk Management and Regulatory Compliance Coordinator provides leadership for safety, accreditation and regulatory activities through relationship with hospital administration and leadership, medical staff leadership, physicians, nurses, and ancillary and allied health departments to improve knowledge and performance for hospital safety, performance improvement and quality initiatives. Assists in the oversight of department staff as directed by the Director and/or Quality Manager. Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all. Provides concurrent case reviews and recommendations to ensure that evidence based best practices are implemented timely. Responsible for independent coordination of program submissions in compliance with federal guidelines. Liaison for the medical staff physician Medical Review and OPPE/FPPE process. This position represents the Office of Clinical Effectiveness at medical staff committees, new hire orientation and hospital leadership meetings by providing accreditation, regulatory, quality and safety updates. Coordinates annual accreditation activities. Serves as the patient safety designee as needed. Responsible for planning, implementation & monitoring of interventions to ensure evidence-based practices are implemented and participates in and/or leads performance improvement committees as directed. Prepares reports and statistical analysis for medical staff and hospital leadership meetings. Routinely utilizes sensitivity and diplomacy in daily interactions with others as many deal with sensitive, confidential or controversial information. Adheres to and enforces the AdventHealth Corporate Compliance Plan, the rules and regulations of all applicable local, state, and federal agencies, and the standards of applicable accrediting bodies. Assures facilitation of the patient grievance process as required by state and federal statutes. Adheres to and enforces the AdventHealth Corporate Compliance Plan, the rules and regulations of all applicable local, state, and federal agencies, and the standards of applicable accrediting bodies.

The value you’ll bring to the team:

· PRINCIPAL DUTIES AND JOB RESPONSIBILITIES:

SERVICE:

· Serves as a hospital content expert on performance improvement projects, accreditation and safety. Provides leadership and support regarding questions from staff, leaders and physicians on performance improvement, quality projects, regulatory and accreditation. Utilizes outside resources for complex questions to ensure correct communication and interpretation (i.e. TJC intranet, ECRI, QualityNet websites).

· Participates in collaboration with or as the designee for the Quality Director, on AHS quality initiatives and/or collaboratives. This may include but is not limited to: Glycemic management, Partnership for Patients/HIIN, AHRQ safety indicators as assigned. Assists with data management, performance improvement, medical record review and meeting organization to help ensure initiative success and goals are met. Utilizes appropriate PowerInsight (PI) reports to coordinate performance improvement and safety projects.

· Liaison for the medical staff physician Medical Review and OPPE/FPPE process. This position represents the Office of Clinical Effectiveness at medical staff committees, performance review councils and hospital leadership meetings by providing regulatory, quality and safety updates as assigned. Responsible for ensuring all cases referred to Medical Review are dealt with according to hospital Medical Review policy and medical staff bylaws. This may include screening, reviewing with appropriate department chairman, preparing cases to be brought to committee, completing agenda/minutes for committee meeting, communicating committee decisions to involved medical staff providers and providing updates to Medical Executive Committee and hospital Executive Council. Maintains familiarity with medical staff bylaws as an internal content expert.

· Responsible for maintaining daily screening process for all inpatient admission throughout hospital. Utilizes appropriate PI reports as verification tool to ensure all patients with coded diagnosis for core measure conditions after discharge have all appropriate safety measures addressed. When discrepancy or variance is noted, responsible for notifying front line nurse, physician and/or leadership to ensure correction is made prior to discharge or chart completion deadline. Responsible for performing error checking and validation procedures in conjunction with Premier/Florida Hospital Association liaison prior to monthly submission. Responsible for completing all abstraction by AHS monthly and CMS quarterly deadlines.

· Plans, implements & monitors interventions to ensure evidence-based practices are implemented and participates in and/or leads performance improvement committees and teams. Leads special projects for the Chief Medical Officer, Quality Director and Quality Manager while using judgment for the level of discretion and confidentiality needed.

· Prepares reports and statistical analysis for medical staff and hospital leadership meetings. Routinely utilizes sensitivity and diplomacy in daily interactions with others as many deal with sensitive, confidential or controversial information.

· Patient safety and/or risk management designee when quality director and risk manager are out of the hospital or need additional support. Completes and analyzes quality event timelines, root cause analysis timelines, review core measure cases, review risk events, notify regulatory bodies of any Code 15 or other reportable events, and identify care variation in case reviews.

· Ensures facilitation of the patient grievance process as required by state and federal statutes. Ensures that grievances are investigated and directs inquiries and complaints to appropriate directors and managers for follow up. Participates in grievance mediations when necessary. Active member of the board delegated grievance committee. Completes investigations of complaints about medical care which involve a member of the medical staff and communicates need for referral to the Performance Improvement Committee, medical director, Patient Safety Committee, Medical Review Committee and/or Citizenship Committee to the Risk Manager. Maintains data collection and grievance tracking and trending to include unsolicited complaints as well as solicited comments (Gallup surveys, comment boxes, etc.). Independently manages patient relations hotline for grievance/complaint calls and directs information to the appropriate member of the leadership team as appropriate.

· Responsible for all incoming and outgoing sensitive regulatory correspondence, ensuring appropriate follow-up, including drafting of response correspondence. Immediately advises Director and/or Managers of mail requiring a response and/or important or urgent mail. Writes regulatory compliance correspondence on behalf of Director and/or Managers as necessary.

· Oversees compliance with the Ethics, Rights, and Responsibilities standards for The Joint Commission. Ensures leadership and employee education on patient rights and responsibilities. Assists with New Hire Orientation and Nursing Orientation to provide education on performance improvement, quality measures, accreditation and safety. Provides quarterly staff education and coordinates patient safety, risk management, accreditation and regulatory activities for skills fair. May be asked by Quality Director and/or Quality Manager to be responsible for developing weekly performance improvement, safety and accreditation tips education flyer and for completing rounds in clinical and non-clinical areas routinely to serve as a resource to staff.

· Provides analysis of provider-specific and Quality Advisor reports from the Premier database and produces recommendations for performance improvement projects to hospital leadership. Responsible for evaluation and completion of Premier Error Workbooks by the monthly deadline to ensure availability of evidence-based data analysis.

· Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all. Provides concurrent case reviews and recommendations to ensure that evidence based best practices are implemented timely. Responsible for independent coordination of program submissions in compliance with federal guidelines.

· Responsible for reviewing patient medical records to determine adherence to key quality and safety initiatives in addition to quality measures. When discrepancy or variance is noted, responsible for notifying front line nurse, physician and/or leadership to ensure correction is made prior to discharge or chart completion deadline. Provides leadership for providers, managers and team members on accreditation awareness, safety initiatives, quality measures, and performance improvement projects. Leads and participates in performance improvement initiatives to improve processes, value-based purchasing scores and to ensure patients receive evidence-based care according to the CMS and The Joint Commission standards.

· Manages complex calendars to coordinate meetings and events for internal and external stakeholders. Plans for and ensures the orderly occurrence of special events as scheduled. Prepares detailed itineraries when applicable to include events such as dinner meetings, physician meetings and presentations, direct reports’ retreats and special parties/receptions. Coordinates the attendees, materials and resources to ensure streamlined, meaningful performance improvement and risk management meetings/committees/ events. Completes documentation within 48 hours or two business days for review. Ensures follow up and includes action items in future agendas.

· Administers and facilitates debriefing for the annual Safety Culture Survey, Joint Commission survey preparedness/ continuous safety rounding, and completion and submission of the Leapfrog Survey.

· Coordinates annual TJC standards review with executive team and directors and acts as Joint Commission Survey Liaison.

· Assists Quality Director and/or Quality Manager, as assigned, to help with quality and safety initiatives throughout the year. Performs other duties as assigned. This includes, but is not limited to, maintaining department files in compliance with regulatory guidelines and maintain intranet for accreditation, patient safety, and performance improvement.

FINANCE:

· Considers the financial implications, safety implications and clinical outcomes when making recommendations, evaluating technology and products, and developing policies and procedures

· Participates in cost-benefit assessments, efficacy studies and product evaluations using a systematic approach

· Incorporates fiscal assessments into program evaluations and/ or reports

· Maintains compliance with departmental budget

GROWTH:

· Attends 75% of the role-specific region council meetings

· Completes a professional development plan at least yearly

· Maintains current knowledge through the review of best practices, evidence-based research, consensus, and guidelines

· Actively participates in local professional organization

Qualifications

EDUCATION AND EXPERIENCE REQUIRED:

· Bachelor’s degree

· Minimum of three years’ healthcare experience

· Preparing and presenting professional presentations to executive leadership teams

· Accreditation activities and survey preparation

· Provider performance improvement activities

EDUCATION AND EXPERIENCE PREFERRED:

· Bachelor’s degree in a healthcare related field

· Experience with regulatory, patient safety, Peer Review or OPPE process

· Healthcare related performance improvement or project management experience

· Proven ability in areas of leadership/ supervision, knowledge of regulatory aspects of healthcare, QA/QI principles, education and outcomes

LICENSURE, CERTIFICATION OR REGISTRATION PREFERRED:

· Six Sigma Performance Improvement Certification

· LEAN Performance Improvement Certification

· Team STEPPS Certification

· Certified Professional in Healthcare Risk Management (CPHRM)

· Certified Professional in Patient Safety (CPPS)

· Certified Joint Commission Professional (CJCP)

· Certified Professional in Healthcare Quality (CPHQ)

This facility is an equal opportunity employer and complies with federa

Category: Risk Management

Organization: AdventHealth Waterman

Schedule: Full-time

Shift: 1 - Day

Req ID: 24014006

We are an equal opportunity employer and do not tolerate discrimination based on race, color, creed, religion, national origin, sex, marital status, age or disability/handicap with respect to recruitment, selection, placement, promotion, wages, benefits and other terms and conditions of employment.