Clinical Compliance RN in Raleigh, North Carolina at Crandells Enterprises Inc

Essential Duties and Responsibilities
Clinical Compliance

* Conduct comprehensive audits of medication administration records (MAR/eMAR/QMAR) to ensure medication accuracy and compliance.

* Review QMAR documentation daily to identify medication discrepancies, omissions, documentation errors, and compliance concerns.

* Perform medication chart audits and medication storage inspections.

* Audit nursing documentation for completeness, accuracy, timeliness, and regulatory compliance.

* Conduct routine clinical record reviews, including admissions, physician orders, treatment plans, medication records, and discharge documentation.

* Ensure all clinical documentation meets federal, state, payer, and accreditation requirements.
Regulatory Compliance
Monitor organizational compliance with:

* HIPAA

* DHHS Regulations

* CMS Standards

* CARF Standards

* Joint Commission Standards

* North Carolina Behavioral Health Regulations

* Other applicable state and federal regulations
Remain current on regulatory changes and communicate updates to leadership.
Quality Assurance & Performance Improvement

* Participate in organizational Quality Improvement (QI) initiatives.

* Identify compliance trends and recurring deficiencies.

* Develop corrective action plans.

* Monitor implementation and effectiveness of corrective actions.

* Assist leadership with preparation for audits, licensing reviews, accreditation surveys, and inspections.

* Participate in internal mock surveys and compliance readiness activities.
Staff Training & Development
Provide intentional, observation-based clinical education to improve staff performance.
Responsibilities include:

* Conduct medication compliance training once each month at both the Wake County and Pitt County locations.

* Train Paraprofessionals (PPs), Qualified Professionals (QPs), and clinical staff on medication administration standards, documentation requirements, infection control, and regulatory expectations.

* Provide immediate coaching following observed deficiencies.

* Develop individualized education based upon staff performance and identified trends.

* Serve as a clinical resource by proactively addressing staff questions and concerns before they become compliance issues.
Incident Investigation
Investigate:

* Medication errors

* Medication omissions

* Clinical incidents

* Documentation deficiencies

* Compliance violations

* Reportable events
Provide findings, recommendations, and corrective actions to leadership.
Policy & Procedure Development

* Develop new compliance policies.

* Review existing clinical policies.

* Update procedures based on regulatory changes and organizational needs.

* Recommend process improvements that strengthen compliance and improve patient outcomes.
Leadership Collaboration
Collaborate with executive leadership to:

* Correct identified deficiencies

* Improve clinical processes

* Strengthen regulatory readiness

* Reduce organizational risk

* Enhance quality of care
Serve as the liaison between:

* Clinical staff

* Executive leadership

* Regulatory agencies

* Surveyors

* External healthcare partners
Travel Requirements
Travel is required.
The Clinical Compliance RN must:

* Travel between Wake County and Pitt County.

* Travel to the Pitt County location a minimum of twice per month.

* Conduct onsite medication cart audits and compliance reviews.

* Attend meetings as requested by executive leadership.
Reliable transportation is required.