This Quality Regulatory Specialist directly reports to the Senior Director of Clinical Operations. The Quality Regulatory Specialist is responsible for leading system-wide activities to evaluate and improve adherence to accreditation standards as well as state and federal regulatory agencies, i.e. Nevada Department of Public Health (NVPD). This includes facilitating and ensuring ongoing survey readiness for accreditation as well as regulatory complaint investigations. Serve as a resource for interpretation of regulatory and accreditation standards. Interpret standards in relation to clinical operations policies and practices. Conducts patient and system tracers in patient care areas through observation of practice. Actively consults with quality teams to ensure goals are achieved. Primary interface with regulatory agencies. Participates in improving organizational performance through improvement activities and process engineering. Assist in the development of actions planning with all levels of organizational leadership. Provides orientation to regulatory requirements and new leaders and staff members and others as assigned. Supports Regulatory Readiness & Accreditation as well as Patient Safety activities and initiatives and ad hoc work groups addressing areas of non-compliance. Maintains a system for organizing required documents.
Essential Duties: 1. Assessment - Assesses survey readiness and ensures all implementation of all applicable Patient Safety initiatives a. Evaluates prior survey deficiencies and current survey standards for compliance. b. Coordinators and provides leadership for survey readiness rounds and provides a rotating calendar of visits to different healthcare facilities. c. Complies and disseminates information to the applicable senior director and CMO on areas that require action to ensure compliance d. Ensures all quality and patient safety rounds identify opportunities to improve care and outcomes e. Identifies, develops and evaluates quality improvement initiatives particularly as they relate to regulatory agencies. f. Trains and develops other departmental personnel in quality improvement and regulatory oversight. 2. Organizational Metrics: Gathers, identifies trends and solutions for the leadership team including but not all inclusive: KPI, Utilization, Patient satisfaction, After hours care. Prepares reports for leadership presentations. 3. Consultation - Provides consultation to individuals/departments concerning regulatory standards and assists with interpretation of new or revised standards; Recommends methods/actions to achieve regulatory compliance; Serves as a consultant for other projects as assigned. 4. Implementation: Implements corrective actions including but not limited to providing written responses to any RFIs (Recommendation for improvement), or audit deficiencies related to regulatory compliance. Ensures that the applicable database is updated with any corrective action plans and follows up with the applicable department director regarding the proposed action plan 5. Collaboration - Collaborates with all members of the healthcare team to promote an organized approach to the hospitals survey process. Facilitates survey readiness teams. Cross-trained in the functions of Quality and Outcomes management and Peer Review processes to collaborate with department staff members and provide coverage as necessary. 6. Communication: Communicates any audit findings to the senior director and CMO along with any proposed or implemented action plans. Attends any applicable hospital or medical staff committee meetings to communicate information on Survey Readiness 7. Education Provides In-service to clinical staff and medical staff as appropriate to ensure survey preparedness. 8. Incident Reporting: RL Datix and RL6 Administration. Oversight of incidents reporting systems, trending of incidents. Presentations of trends. 9. Keeps updated on all regulations that pertain to Ambulatory Care licensure and updates policies and procedures as necessary 10. Member of the policy and forms committee and works closely with the policy coordinator 11. Provides supervision and oversight for regulatory compliance staff ensuring a cohesive well informed team 12. Performs other duties consistent with professional training and experience and department goals and functions. Required Qualifications: Req Bachelor's degree Health-Related Professions Degree in healthcare administration, nursing, or related field required Req 3 years 3-5 years of regulatory, accreditation, and quality improvement experience Req Working knowledge of regulatory agencies accreditation and regulatory requirements Req Ability to facilitate working sessions with cross-functional teams Preferred Qualifications: Pref Master's degree MHA, MBA, Regulatory Science degree or equivalent degree preferred Pref Experience in Ambulatory Care setting is desired Pref Experienced with multiple facility-wide accreditation survey is preferred Required Licenses/Certifications: Req Certified Professional in Healthcare Quality - CPHQ (NAHQ) CPHQ or HACP certification within 2 years of hire. Req Fire Life Safety Training (LA City) If no card upon hire, one must be obtained within 30 days of hire and maintained by renewal before expiration date. (Required within LA City only)
The annual base salary range for this position is $81,120.00 - $133,010.00. When extending an offer of employment, the University of Southern California considers factors such as (but not limited to) the scope and responsibilities of the position, the candidates work experience, education/training, key skills, internal peer equity, federal, state, and local laws, contractual stipulations, grant funding, as well as external market and organizational considerations. About University of Southern California (USC)
USC is the leading private research university in Los Angeles—a global center for arts, technology and international business. With more than 47,500 students, we are located primarily in Los Angeles but also in various US and global satellite locations. As the largest private employer in Los Angeles, responsible for $8 billion annually in economic activity in the region, we offer the opportunity to work in a dynamic and diverse environment, in careers that span a broad spectrum of talents and skills across a variety of academic and professional schools and administrative units. As a USC employee and member of the Trojan Family—the faculty, staff, students, and alumni who make USC a great place to work—you will enjoy excellent benefits, including a variety of well-being programs designed to help individuals achieve work-life balance.
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