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Regulatory Consultant - Bayfront Health

 

Position Summary

Functions as a consultant to Orlando Health in the area of healthcare accreditation regulations, standards, and clinical performance improvement. Please note this position will be on-site at Bayfront Health located in St. Petersburg, Florida.


Responsibilities

  • Coordinates external body regulatory/accreditation surveys for the organization. Communicates directly with The Joint Commission (TJC) account executive or Standards Interpretation Group for clarification of standards or requirements.
  • Responsible for completion of components of The Joint Commission application for submission of required data and documentation.
  • Ensures accuracy of all data submitted to regulatory or accreditation organizations.
  • Performs mock surveys to evaluate compliance with The Joint Commission/CMS standards and requirements. Trains additional
    identified team members to perform focused mock surveys using specific tracer tools.
  • Develops tracer tools or other specific focus tools for use in mock survey process or evaluation of compliance with specific regulatory/accreditation/ certification requirements.
  • Provides oversight for Orlando Health Patient Care Policies and Procedures and compliance with National Patient Safety Goals.
  • Educates organization leadership and medical staff on changes to accreditation /regulatory requirements.
  • Provides regulatory guidance and support to medical staff and operations leaders /councils pursuing specific TJC certifications.
  • Coordinates application submission, site survey and follow up actions.
  • Actively performs audits to evaluate compliance on regulatory requirements. Directs development and implementation of action plans to address non-compliance.
  • In conjunction with site leadership, actively facilitates site Regulatory Council to support ongoing TJC readiness and sustainability.
  • Assists internal customers with performance improvement initiatives which support the Strategic Goals of Orlando Health.
  • Directs improving compliance with and understanding of all healthcare regulations and standards.
  • Mentors and provides guidance for the development of educational opportunities for the organization relative to standards and accreditation regulations.
  • Works with Orlando Health's leaders to communicate mock and actual survey findings and directs the completion of corrective action plans to address deficiencies.
  • Directs development and maintenance of unit based medical record review data base. Analyzes data, interprets results. Facilitates development of action plans with nursing unit leaders to address areas of non-compliance.
  • Develops and maintains effective working relationship with the medical and operations staff.
  • Maintains reasonably regular, punctual attendance consistent with Orlando Health policies, the ADA, FMLA and other federal, state and local standards.
  • Maintains compliance with all Orlando Health policies and procedures.

Other Related Functions

  • Represents the Regulatory Department and Orlando Health at external meetings and seminars. Adheres to Orlando Health policies
    and procedures, value statement and PROMISE Standards.
    Attends external accreditation/regulatory education sessions/programs to enhance knowledge of regulatory/accreditation requirements. Actively seeks learning experiences and assumes responsibility for own professional growth.
  • Works closely and in collaboration with all departments of Orlando Health.
  • Demonstrates excellent verbal, written, and presentation skills in order to communicate cooperatively and constructively with physicians and members of the healthcare team.

Qualifications

Education/Training

  • Bachelor's degree in healthcare, nursing, allied health or closely related field.

Licensure/Certification

  • If RN, maintain license with Florida Department of Health – renewed biannually
  • If Allied Health professional, maintain license with Florida Department of Health as appropriate for profession.


Experience

  • Five (5) years of clinical or related experience, including experience in healthcare quality/performance improvement projects.

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