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AVP Clinical Regulatory Compliance

AVP Clinical Regulatory Compliance

Job Description

Directs an ongoing quality program that objectively and systematically monitors, evaluates, and improves the quality of patient care and outcomes while ensuring compliance with all regulatory and accrediting entities.   Utilizes complex data sets to analyze, trend, and identify opportunities for improvement.  Leads Quality team including Stroke Coordinator, Sepsis Coordinator and Clinical Documentation Improvement Specialists in interdisciplinary performance improvement activities to improve quality throughout the facility.  Continuously evaluates work processes and design; serves as a leader ensuring quality/ performance improvement, and service delivery to meet stakeholder needs.
  • Leads organizational compliance and performance improvement efforts including but not limited to focusing on Core Measures, The Joint Commission initiatives, and all other accrediting and regulatory entities.
  • Assists with application and survey process for all Quality Distinctions including but not limited to:  Society for Thoracic Surgeons (STS),  National Accreditation Program for Breast Centers (NAPBC), American Society for Metabolic and Bariatric Surgery (MBSAQIP)
  • Develops audit tools and processes and directs activities to coordinate open and closed chart reviews as well as mock tracer activities to ensure survey readiness preparations. 
  • Develops and maintains survey readiness plan and collaborates with senior leadership for day of survey coordination as well as post survey action plans and compliance monitoring. 
  •  Serves as a leader for quality performance review committees
  •  Leads nursing peer review committee including case review, action plan development, implementation and follow through coordinating with CNO and Education Department as appropriate.
  • Coordinates Clinical Research Activities including Institutional Review Board (IRB) activities
  • Works collaboratively with the Director of Risk Management/Patient Safety Officer to investigate adverse events and develop performance improvement strategy to improve quality and safety.
  •  Responsible for all required reporting to The Joint Commission consistent with accreditation requirements.
  •  Serves as Core Measure subject matter expert evaluating, educating, and designing tools and processes to ensure understanding and compliance with requirements.
  • Leads the Clinical Documentation Improvement team to assist healthcare providers with complete, accurate, timely and specific medical record documentation which appropriately describes patient acuity and risk.

Job Requirements

  • Undergraduate Degree in Healthcare field
  • Quality Management and Regulatory Acute Care Experience

Job Snapshot

Employment Type Full-Time
Job Type QA - Quality Control, Finance, Banking
Education 4 Year Degree
Experience Not Specified
Manages Others Not Specified
Industry Other Great Industries
Required Travel Not Specified
Job ID 02525-8616
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AVP Clinical Regulatory Compliance


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