Job Requirements
Position Summary
The Manager of Regulatory Readiness-SHRC guides and supports the hospital Regulatory Compliance process. Participates on cross-functional PI (Performance Improvement) teams throughout the hospital. Advances the concepts of SPC (Statistical Process Control) to achieve measurable improvements. Supports effective decision making related to clinical, operational, and service activities through the provision of reports to the Performance Management Council (PMC) and Skilled Quality Council (SQC). Assists with preparation of regulatory readiness through standing committee, ongoing education, and mentor of internal leadership for regulatory compliance areas.
Minimum Requirements
Education
- Bachelor's degree in Nursing or related healthcare field
Experience
- Minimum of five years' management experience in a healthcare setting with experience in quality/performance management and statistical process control
- Requires proficiency as presenter, teacher, facilitator, negotiator and communicator
- Must be able to demonstrate strong planning, organizational and computer skills
License/Registration/Certifications
- Current South Carolina Registered Nurse License or current state license in area of clinical training
Preferred Requirements
Preferred Education
- Master's degree in Nursing or related healthcare field
Preferred Experience
Preferred License/Registration/Certifications
- Certified Professional in Healthcare Quality
Core Job Responsibilities
- Responsible for all state, and federal regulatory standards and compliance excluding financial compliance
- Serves as an internal resource on regulatory compliance
- Assists with liaison activities with all regulatory agencies
- Improves Regulatory Compliance throughout the hospital with standards. Supports the hospital in becoming a quality leader
- Serves as a resource for FMEA, Quality Assessment Performance Improvement Teams, benchmarking, process re-design, award, and certification applications as directed
- Supports the Patient Safety program development, compliance, and patient safety improvement initiatives, assist the Director of Quality with maintaining the hospitals Patient Safety organization
- Ensures Safety documentation is current
- Completes concurrent and retrospective audits of clinical documentation and collection of surveillance data.
- Enters audit and surveillance results into hospital and nursing home data collection system(s)
- Assists with effective utilization of hospital variance system and electronic medical record system data by building new reports, obtaining data as requested and revising current focus studies to meet concurrent and retrospective audits for hospital