Quality and Regulatory Specialist - Quality Assurance

The Quality Regulatory Specialist is responsible for leading system-wide activities to evaluate and improve adherence to accreditation standards as well as state and federal regulatory agencies, i.e. Centers for Medicare and Medicaid Services, local State Department of Public Health. This includes facilitating and ensuring ongoing survey readiness for accreditation as well as regulatory complaint investigations. Serve as a resource for interpretation of regulatory and accreditation standards. Interpret standards in relation to clinical operations policies and practices. Conducts patient and system tracers in patient care areas through observation of practice. Actively consults with quality teams to ensure goals are achieved. Primary interface with regulatory agencies. Participates in improving organizational performance through improvement activities and process engineering. Assist in the development of actions planning with all levels of organizational leadership. Provides orientation to regulatory requirements and new leaders and staff members and others as assigned. Supports Regulatory Readiness & Accreditation as well as Patient Safety activities and initiatives and ad hoc work groups addressing areas of non-compliance. Maintains a system for organizing required documents.

Essential Duties:

• 1. Assessment - Assesses survey readiness and ensures all implementation of all applicable Patient Safety initiatives a. Evaluates prior survey deficiencies and current survey standards for compliance. b. Coordinates and provides leadership for survey readiness rounds and provides a rotating calendar of visits to different healthcare facilities. c. Complies and disseminates information to the applicable senior director and CMO on areas that require action to ensure compliance. d. Ensures all quality and patient safety rounds, identify opportunities to improve care and outcomes. e. Identifies, develops, and evaluates quality improvement initiatives particularly as they relate to regulatory agencies. f. Trains and develops other departmental personnel in quality improvement and regulatory oversight.
• 2. Organizational Metrics: Gathers, identifies trends and solutions for the leadership team including but not all inclusive: KPI, Utilization, Patient satisfaction, After hours care. Prepares reports for leadership presentations.
• 3. Consultation - Provides consultation to individuals/departments concerning regulatory standards and assists with interpretation of new or revised standards; Recommends methods/actions to achieve regulatory compliance; Serves as a consultant for other projects as assigned.
• 4. Implementation: Implements corrective actions including but not limited to providing written responses to any RFI’s (Recommendation for improvement), or audit deficiencies related to regulatory compliance. Ensures that the applicable database is updated with any corrective action plans and follows up with the applicable department director regarding the proposed action plan
• 5. Collaboration - Collaborates with all members of the healthcare team to promote an organized approach to the hospital’s survey process. Facilitates survey readiness teams. Cross-trained in the functions of Quality and Outcomes Management and Peer Review processes to collaborate with department staff members and provide coverage as necessary.
• 6. Communication: Communicates any audit findings to the senior director and CMO along with any proposed or implemented action plans. Attends any applicable hospital or medical staff committee meetings to communicate information on Survey Readiness
• 7. Education – Provides In-service to clinical staff and medical staff as appropriate to ensure survey preparedness.
• 8. Incident Reporting: RL Datix and RL6 Administration. Oversight of incidents reporting systems, trending of incidents. Presentations of trends.
• 9. Keeps updated on all regulations that pertain to organization licensure and updates policies and procedures as necessary
• 10. Member of the policy and forms committee and works closely with the policy coordinator
• 11. Provides supervision and oversight for regulatory compliance staff ensuring a cohesive well informed team
• 12. Performs other duties consistent with professional training and experience and department goals and functions.

Required Qualifications:

• Req Bachelor's degree Health-Related Professions Degree in healthcare administration, nursing, or related field required

• Req 3 years 3-5 years of regulatory, accreditation, and quality improvement experience
• Pref Experience in Ambulatory Care setting is desired

• Req Working knowledge of regulatory agencies accreditation and regulatory requirements
• Req Ability to facilitate working sessions with cross-functional teams

Preferred Qualifications:

• Pref Master's degree MHA, MBA, Regulatory Science degree or equivalent degree preferred
• Pref Experience in Ambulatory Care setting is desired
• Pref Experienced with multiple facility-wide accreditation survey is preferred

Required Licenses/Certifications:

• Req Certified Professional in Healthcare Quality - CPHQ (NAHQ) CPHQ or HACP certification within 2 years of hire.
• Req Fire Life Safety Training (LA City) If no card upon hire, one must be obtained within 30 days of hire and maintained by renewal before expiration date. (Required within LA City only)

The annual base salary range for this position is $81,120.00 - $133,010.00. When extending an offer of employment, the University of Southern California considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate’s work experience, education/training, key skills, internal peer equity, federal, state, and local laws, contractual stipulations, grant funding, as well as external market and organizational considerations.