Regulatory Performance Improvement Team Coordinator
Location: Danville, Pennsylvania
Type: Full Time
Internal Number: R-24202
b Profile Summary Responsible for coordinating a platform-wide Regulatory Performance Improvement program to monitor compliance to regulations and standards governing the operation of hospitals and the delivery of patient care services, as established by federal and state mandates, CMS, accreditation bodies as well as internal policies and procedures. Responsibility involves on-going education and consultation with department leaders, operations managers and administrators to keep them advised of current requirements and changes; monitoring hospital-wide compliance on an on-going basis; ensuring proper procedures for reporting and documenting conformance to standards; and developing methods for corrective action when problems are identified. Provides direction and leadership to the platform Performance Improvement program. Manages complex projects, facilitates change and regulatory improvements in quality and safety.
Provides employee supervision and supports the daily operations of activities for the Regulatory Performance Improvement Department.
Develops procedures for implementing and monitoring compliance to regulations in conjunction with Director, Leadership, physicians, nurses and other staff.
Participates in recruitment and retention of all professional and paraprofessional staff.
Supports Regional Director with staffing plans to support the department including position descriptions, performance evaluations, action plans, employee goal setting, hiring, promotion and disciplinary actions
Ensures, in conjunction with Director, that all administrative policies and procedures pertaining to Regulatory Performance Improvement are current and reviewed annually.
Provides education and consultation on Proactive Risk Assessment and FMEA methodology.
Contributes to the development of quality reports to provide analytics for Division staff and our customers Participates in major survey preparation, and assists in development of plans of correction, implementation strategies, and continuing oversight Participates in Joint Commission Sentinel Event reporting process to identify Root Causes.
Completes all submissions to the Joint Commission within required time frames.
Active member of RCA team.
Maintains knowledge of regulatory agencies' standards and regulations.
Develops plans for platform and hospital mock survey activities. Coordinates readiness rounds on inpatient and hospital based clinics in preparation for state and federal surveys.
Leads preparation and planning for hospital PI Committee meetings with chairperson and other department staff.
Assures confidentiality of information coming into and being disseminated out of the Regulatory Performance Improvement Department.
Works collaboratively with Risk Management and Patient Safety Department and Infection Prevention and Control Department to assure compliance with related healthcare regulations.
Work is typically performed in an office environment. Accountable for satisfying all job specific obligations and complying with all organization policies and procedures. The specific statements in this profile are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job.
Registered Nurse with quality experience, preferably with regulatory standards for Department of Health and Joint Commission preferred.
Employee Value Proposition: Flexible, top rated quality organization.
Bachelor's Degree-Healthcare Related Degree (Required)
Minimum of 3 years-Clinical (Required)
Certification(s) and License(s)
OUR PURPOSE & VALUES: Everything we do is about caring for our patients, our members, our students, our Geisinger family and our communities. KINDNESS: We strive to treat everyone as we would hope to be treated ourselves. EXCELLENCE: We treasure colleagues who humbly strive for excellence. LEARNING: We share our knowledge with the best and brightest to better prepare the caregivers for tomorrow. INNOVATION: We constantly seek new and better ways to care for our patients, our members, our community, and the nation. SAFETY: We provide a safe environment for our patients and members and the Geisinger family We offer healthcare benefits for full time and part time positions from day one, including vision, dental and domestic partners.* Perhaps just as important, from senior management on down, we encourage an atmosphere of collaboration, cooperation and collegiality. We are an Affirmative Action, Equal Opportunity Employer Women and Minorities are Encouraged to Apply. All qualified applicants will receive consideration for employment and will not be discriminated against on the basis of disability or their protected veteran status.
We are an Affirmative Action, Equal Opportunity Employer Women and Minorities are Encouraged to Apply. All qualified applicants will receive consideration for employment and will not be discriminated against on the basis of disability or their protected veteran status.
At Geisinger, our innovative ideas are inspired by the communities we serve – like our Fresh FoodFarmacy, a program that delivers life-saving healthy alternatives to patients with diabetes. With additional tools like our MyCode Community Health Initiative, one of the first health system genome sequencingprograms, and our new asthma app suite that we developed in partnership with AstraZeneca, it’s no wonder we’re ranked one of the Top 5 Most Innovative Healthcare Systems by Becker's Hospital Review. We continually work towards continuous improvement in a culture where everyone has a voice and firmly believe that better begins with all of us.Founded more than 100 years ago, Geisinger serves more than three million residents throughout central, south-central and northeastern Pennsylvania and southern New Jersey. Our physician-led system is comprised of 30,000 employees, including 1,600 employed physicians, and consists of 13... hospital campuses, the Geisinger Health Plan, Geisinger Commonwealth School of Medicine and two research centers. What you do at Geisinger shapes the future of health and improves lives – for our patients, communities, and you.