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Position Details

Department: Accreditation and Regulatory
Category: Legal/Risk/Reg Compliance
Location: Phoenix
Posting #: 491022
Date Posted: 12/19/2019
Employee Type: Regular

Position Summary

The Regulatory Coordinator is a leader with enterprise wide responsibility related to maintaining a continuous level of preparation for all announced and unannounced surveys. This position utilizes high reliability principles to evaluate and address adherence to state licensing laws, CMS Conditions of Participation, Joint Commission standards or other deeming agencies.

PCH Values

  • Family-Centered care that focuses on the need of the child first and values the family as an important member of the care team
  • Excellence in clinical care, service and communication
  • Collaborative within our institution and with others who share our mission and goals
  • Leadership that set the standard for pediatric health care today and innovations of the future
  • Accountability to our patients, community and each other for providing the best in the most cost-effective way.

Position Duties

  1. Regulatory and Accreditation Expertise
    • Serves as primary subject matter expert for Accreditation standards (Joint Commission), CMS conditions of participation and State licensing regulations. Primary responsibility for survey process, survey process changes, and compliance results, new and changes standards.
    • Leads all internal efforts to assess, improve and proactively prepare the organization for unannounced surveys with development of effective action plans to improve performance.
  2. System Assessment aligned with Safety and Outcomes
    • Develops and manages a comprehensive system for assessing organizational compliance and risk based upon outcomes, concurrent observation of practices, tracer findings, mock survey findings, and actual survey findings and other methods.
    • Performs risk assessments in a variety of settings and creates improvement plans by prioritization of risk factors. Develops effective improvement plans with leadership involvement.
    • Provides updates on progress for organizational improvements, aligns resources and communicates this information to the appropriate personnel.
  3. Infrastructure development including policies, procedures and operational standardization.
    • Develops and manages an effective organization wide assessment comparing regulations to practice. Identifies gaps and works with local area management for improvement. Manages internal system for continual preparation including education and practice operation review related to all relevant survey regulations and standards.
    • Serves as a subject matter expert related to policies and procedures, which will support operations and compliance with regulatory/ accrediting agencies.
  4. Subject Matter Expert for Healthcare Environment and Safety Methodology
    • Serves as a subject matter expert as related to internal quality and performance standards. Familiarity with improvement science methodology using tools and methods as it relates to regulatory/accreditation risk points and improvement work.
    • Supports facility leadership to identify areas for improvement and educates practices on tools and methods as needed.
    • Participates in formal improvement teams as needed related to regulatory and accreditation issues.
    • Identifies learning needs and actively drives personal improvement. Is able to assess skill level related to improvement activity, organizational change and other regulatory related issues. Participates in professional organizations and national/state education programs and applies learning to improve organization and personal performance.
  5. Performs miscellaneous job related duties as requested.

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Position Qualifications

Please review the following qualifications and specify whether you meet each of the requirements listed.
Do you meet this requirement?
Education
1. Bachelors`s Degree in Nursing or Healthcare field Required
2. Master`s Degree or related experience in Healthcare field Preferred
Do you meet this requirement?
Experience
1. Working knowledge of Joint Commission standards, CMS Conditions of Participation, and State licensing laws. Required
2. Five (5) or more years experience in healthcare/medical group setting Required
3. Computer competency, including word processing, spreadsheet skills and the ability to master software programs in Windows or other applications Required
4. One or more years experience using of improvement science methodology and tools Preferred
Do you meet this requirement?
Certifications/Licenses/Registries
1. Healthcare Quality (CPHQ) certification or aligned specialty certification Preferred
2. Project Management Certification Preferred
Do you meet this requirement?
Special Skills
1. Demonstrates independent judgment, autonomy and initiative with expert communication skills both written and verbal aligned with effective problem solving skills and leadership ability. Required
2. Knowledge, skills and experience in data collection and analysis techniques Required
3. Computer competency, including word processing, spreadsheet skills and the ability to master software programs in Windows or other applications Required
4. Experience with multidisciplinary teams and facilitating organizational change Preferred
Physical Requirements & Occupational Exposure/Risk Potential
1. Physical Requirement - Feeling (sensing textures and temperatures) Occasionally
2. Physical Requirement - Fine Motor Skills (pinching, gripping, etc) Frequently
3. Physical Requirement - Hearing Constantly
4. Physical Requirement - Pushing/pulling Occasionally
5. Physical Requirement - Reaching Occasionally
6. Physical Requirement - Sitting Frequently
7. Physical Requirement - Standing Frequently
8. Physical Requirement - Stooping/crouching/kneeling/crawling Occasionally
9. Physical Requirement - Talking Constantly
10. Physical Requirement - Walking Frequently
11. Physical Requirement - Near Vision Constantly
12. Physical Requirement - Far Vision Frequently
13. Physical Requirement - Color Discrimination Occasionally
14. Physical Requirement - Use of keyboard, mouse and/or computer equipment Constantly
15. Physical Requirement - Lift up to 35 pounds without assistance Occasionally
16. Occupational Exposure/Risk Potential - Inside office environment Applicable
internal/external
I have reviewed the qualifications, physical requirements and occupational exposure/risk potential for this position and wish to apply