ACCREDITATION AND REGULATORY READINESS SPECIALIST in Randallstown, Maryland at LifeBridge Health

Summary:

The Accreditation and Regulatory Readiness Specialist is responsible for leading system-wide activities to evaluate and improve
adherence to The Joint Commission (TJC) accreditation standards and CMS Conditions of Participation (CoPs) as well as other state
and federal regulatory agencies. This includes facilitating and ensuring ongoing readiness for accreditation surveys as well as
regulatory complaint investigations.

Responsibilities:

Ensures compliance with ongoing regulatory readiness. Serve as a resource for interpretation of regulatory, accreditation and
certification standards (as applicable). Interpretation of relevance of standards in relation to hospital and clinic policies and
practices. Conducts patient and system tracers in patient care areas through observation of practice.

Participates in improving organizational performance through improvement activities and process engineering. Assists in the
development of action plans with all levels of organizational leadership. Provides orientation to regulatory requirements and the
LifeBridge Regulatory Readiness program for new leaders and staff members. Supports Regulatory Readiness & Accreditation
Committee meetings and ad hoc workgroups created to address areas of non-compliance. Maintains a system for organizing and
tracking compliance with required documents.

Maintains tracer database and sources of information for accreditation and regulatory readiness activities. Collects, analyzes and
reports data in support of continuous readiness activities. Facilitates concurrent and closed medical record review audits to assist
in determining compliance with accreditation and regulatory requirements. Disseminates the results of compliance audits, and
tracks follow-up on non-compliance and performance improvement efforts. Assists in assuring accuracy and timeliness of
submissions to regulatory agencies.

Maintains professional knowledge of regulatory requirements from external agencies, along with best practices, and shares this
information within LifeBridge Health. Assists with external agency reviews & on-site surveys as needed. Educates staff on
regulatory requirements, how to identify non-compliance, how to escalate concerns with non-compliance, and on problem-solving
techniques for regaining and maintaining on-going compliance. Ensure compliance with regulatory agencies including meeting
deadlines, when applicable.

Experience:
5-7 years

Education:
Bachelor's Degree Preferred

Licenses And Certification:
Healthcare Related License Preferred