Regulatory Accreditation Quality Analyst

JOB SUMMARY

This position is responsible for assisting in the continual organization readiness for regulatory licensing and survey activities at the federal, state, and local level. The regulatory accreditation quality analyst understands and assists the director of quality to facilitate compliance of all regulatory standards set forth by Joint Commission and CMS or other accreditation agencies. This position will lead tracers and rounds, chart audits, assist with surveys and follow ups, provide education, and other duties associated with accreditation/regulatory requirements. 

 

Required Licenses

• Current/Active State of KY professional LPN/RN license required

Minimum Education

•  LPN/RN

Minimum Work Experience

• Minimum 3 years’ experience in healthcare/acute hospital setting required. Leadership experience preferred.

FUNCTIONAL DEMANDS

Physical Requirements

Sitting - 16-31%

Walking - => 32%

Standing - => 32%

Bending/Squatting - 16-31%

Climbing/Kneeling - 16-31%

Twisting - 16-31%

Visual and Hearing Requirements

Must be able to see with corrective eye wear if needed.

Must be able to hear clearly with assistance if needed.

Physical/Environmental Requirements

Lifting - 0-50 lbs., 50 or more with assistance

Carrying - 0-50 lbs., 50 or more with assistance

Pulling - Up to 100 lbs.

Required Skills

• Must be proficient in Microsoft office suite.
• Will be required to be proficient in AMP and tracer software, and any data software utilized by the health system.
• Will be required to be proficient in Cerner Community works
• Must be motivated and self-directed individual and be able to effectively engage with all levels of staff. 
• Must exercise initiative in the coordination of work activities and be able to effectively manage priorities and meet multiple deadlines.
• Possess excellent oral, written, and interpersonal communication skills in addition to exceptional organizational, analytical, and reasoning skills

ESSENTIAL FUNCTIONS

• Complies with established corporate and departmental policies, procedures, objectives, quality assurance methods, and safety codes. Demonstrates compliance with licensing, regulatory, and accrediting agency deadlines as required. 
• Consistently demonstrates appropriate and professional communication with patients, customers, and coworkers. Cooperates with leadership and peers to promote an environment of teamwork and collaboration.
• Supports the development of the regulatory program inclusive of the analysis and trending of data related to regulatory compliance.
• Serves as an internal consultant on compliance with state, federal, and agency requirements and collaborates with designated teams on providing education as needed.
• Thorough working knowledge of the Joint commission accreditation manual. Additionally, will be required to have working knowledge of CMS COPs and KY state statutes as applicable. 
• Responsible for identifying compliance issues, compiling and analyzing data for current state of compliance and recommending future state compliance with collaboration with the CNO. Will be responsible for ongoing re-evaluation of compliance. Chart audits for regulatory compliance will be an expectation. 
• Will be responsible for continual survey readiness assessment in the health system and or assigned areas. Active participant and planner for tracer days and trace action planning day.
• ASR program, will ensure compliance with program standards, chart audits and onsite survey readiness.
• Provides leadership to identify opportunities for improvement in a quality patient care and clinical outcomes.
• Participates in performance improvement initiatives, supports and coaches’ multidisciplinary teams to identify, design, implement, and evaluate quality improvement projects as related to tracer and survey findings.
• Responsible for ongoing professional growth and development to assure knowledge is current. Demonstrates knowledge and understanding of the application of quality and performance improvement principles and processes.
• Performs other task to promote quality and compliance for the health system under the direction of the quality director.
• Maintains annual mandatory education requirements specific to position as mandated by TJS and the accreditation programs. 
• Performs all other duties as assigned or requested.