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Accreditation and Regulatory Specialist - Boston, United States - Boston Medical Center
Description
Accreditation and Regulatory Specialist (Nurse) page is loadedAccreditation and Regulatory Specialist (Nurse)
Apply
locations
Boston
time type
Full time
posted on
Posted Yesterday
job requisition id
31071
POSITION SUMMARY:
Under the direction of the Senior Director, Accreditation & Regulatory and working collaboratively, the Accreditation and Regulatory Specialist (Nurse) leads efforts to ensure continual organizational compliance and ongoing readiness with clinical quality and patient safety standards and regulations required by The Joint Commission, Massachusetts Department of Public Health and Center for Medicare and Medicaid Services.
In this role the Specialist proactively plans, implements, coordinates and continually improves the Boston Medical Center's (BMC) efforts related to compliance, accreditation and licensure requirements.
Position:
Accreditation and Regulatory Specialist (Nurse)
Department:
Regulatory Compliance
Schedule:
Full Time
ESSENTIAL RESPONSIBILITIES / DUTIES:
Provides support and content knowledge for The Joint Commission, DPH and CMS standards, regulations and conditions of participation.
Responsible for assisting in the interpretation of regulatory and licensing requirements throughout the organization.
Provides education and consultation to administrative and clinical leadership, staff and faculty throughout BMC regarding the requirements of accreditation and regulatory organizations, using both formal and informal venues, e.g.
presentations, publications, email, computer-based methods.Provides guidance and assistance to departments, sections, units and programs regarding improvements needed to ensure compliance with requirements of TJC, DPH and CMS.
Provides consultation to assist administrative and clinical leaders and their departments in improving performance.Builds effective, supportive, productive relationships with leadership, staff and faculty throughout BMC.
Facilitates and supports the development of tools, policies, and procedures, and learning aids to promote compliance with standards.
Provides new and revised TJC, CMS, DPH standards and interpretations to administrative and clinical leadership, staff and faculty.
Works closely and supports the Senior Director in building effective working relationships with accreditation and regulatory agencies, i.e., The Joint Commission, DPH and CMS.
Responsible for all aspects of the plan to ensure continual readiness with the clinical regulatory and accreditation requirements of the TJC, DPH and CMS.
This includes but is not limited to:
Development, coordination, and implementation of the continual readiness plan
Ongoing assessment of the continual readiness plan; identification of needed improvements; and preparation and implementation of plans to achieve needed improvements
Organizational, department, section, unit and program assessments and identification of risk
Plan and scheduling readiness mock surveys
Completion of annual TJC application
Periodic Performance Review completion and submission
Development of remedial action plans
Supporting the Senior Director on agency requests for revision and corrective action plans
Responsible for communication of the continuous readiness plan to Senior Director and key groups throughout BMC.
Responsible for ensuring preparation of reports assessing institutional, department, section, program and unit compliance with accreditation and regulatory requirements.
Ensure that administrative and clinical leadership are continuously aware of BMC readiness for TJC, DPH and CMS surveys, including description of specific issues that are in need of improvement.
Works closely with Risk Management, Quality Improvement & Patient Safety and Clinical Analytics including coordination of the Joint Commission Performance Improvement and NPSG standards compliance.
Leads a coordinated response to unannounced external accrediting or regulatory agency visits such as DPH, Joint Commission or CMS.Co-chairs TJC Steering Committee.
Responsible for overseeing the BMC policy and procedure system including supporting the chair of the Policy and Procedure Roundtable.
Works with Risk Management on an as-need basis to support BORM and DPH requirements regarding reporting of adverse events and onsite surveys.
Other duties as directed, including the occasional work with non-clinical regulatory agencies such as OSHA.JOB REQUIREMENTS
EDUCATION:
Baccalaureate Degree in Nursing required; Master in Healthcare related field preferred
CERTIFICATES, LICENSES, REGISTRATIONS REQUIRED :
Certification in Accreditation preferred
EXPERIENCE:
2 years of experience with The Joint Commission, DPH and other regulatory requirements and survey processes.
KNOWLEDGE AND SKILLS:
Outstanding team player.
Ability to develop effective relationships with a broad array of people from diverse backgrounds.
Strong interpersonal skills; ability to establish supportive, collegial relationships.
Superior organizational skills to manage a large volume of incoming data, information, reports, etc. in paper and electronic formats.
Ability to create and deliver appealing and compelling presentations to a variety of audiences including clinicians, staff, faculty, administration and governance groups.
Excellent written and verbal communication skills.Demonstrated skill in change management and quality improvement.
Knowledge of clinical terminology.
Strong computer skills including Microsoft Office platform—Word, Access, Excel, E-mail. Web/Internet.
Ability to learn and effectively use computer software, such as electronic health records and data entry.
Our People
Working at Boston Medical Center is more than a job.
It's a chance to make a difference as part of our mission to provide exceptional and equitable care to all.
As anationally-recognized
leader in health equity, nursing, initiatives to combat climate change, and many other areas, BMC is dedicated to improving the health of our community in Boston and beyond.
BMC's mission to provide exceptional care without exception extends to our employees, and we have been recognized as a top employer and best place to work.
A strong sense of teamwork and support for our staff are the bedrock of BMC, as we know that we can only provide exceptional care to patients when our staff are cared for too.
EEO & Accommodation StatementBoston Medical Center is an equal
employment/affirmative
action employer.
We ensure equal employment opportunities for all, without regard to race, color, religion, sex, national origin, age, disability, veteran status, sexual orientation, gender identity and/or expression or any other non-job-related characteristic.
If you need accommodation for any part of the application process because of a medical condition or disability, please send an e-mail toor call to let us know the nature of your request.
Requirements
Boston Medical Center participates in the Electronic Employment Verification Program.
As an E-Verify employer, prospective employees of BMC must complete a background check before beginning their employment at the hospital.
BMC requires all staff to be vaccinated against COVID-19 and flu, as well as receive a booster dose of the COVID-19 vaccine.
According to the FTC, there has been a rise in employment offer scams. Our current job openings are listed on our website and applications are received only through our website.We do not ask or require downloads of any applications, or "apps" job offers are not extended over text messages or social media platforms.
We do not ask individuals to purchase equipment for or prior to employment.To avoid becoming a victim of an employment offer scam, please follow these tips from the FTC:
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