Regulatory Compliance Specialist PRN

Person Memorial Hospital

Who We Are:

At Person Memorial Hospital, we value people and strive to create an environment where individuals are recognized for who they are, not just what they can do. Our community facility boasts 68 beds and offers a range of specialties, including orthopedics, cardiology, general surgery, and emergency medicine. We also have a skilled nursing facility, imaging and laboratory services, and other subspecialty care options.

Where We Are:

Roxboro is north of the busy urban areas of Raleigh, Durham, and Chapel Hill. The town is known for its serene rural landscapes, pleasant climate, and warm small-town hospitality. Surrounded by beautiful hills, lush forests, and farmlands, Roxboro offers a relaxed lifestyle with excellent educational facilities, affordable tax rates, quality healthcare, and various recreational activities.

Position Summary

Assists the Quality Director with regulatory surveys and continuous preparedness. Helps the Quality Director ensure that processes are in place to meet Joint Commission federal, state, and other regulatory requirements. Performs other related duties to include support for Quality Management, Risk Management, Patient Safety, and Patient Satisfaction Initiatives. Performs other duties as requested.

Reports to: Quality Director

Responsibilities of the Position

Data Compilation

Job Description Reporting

Participates in hospital and departmental safety programs.

Assists the Quality Director in ensuring that TJC accreditation requirements are met in addition to other regulatory agencies -state and federal.

Assists the Quality Director in designing and implementing strategies for enhancing compliance by developing education programs and tools for continuous survey readiness.

Provides hospital leaders and departments guidance for interpretation of all regulatory standards.

Develops and coordinates action plans for identified deficiencies as assigned by the Quality Director.

Assists the Quality Director in monitoring compliance through formal and informal processes.

Serves as a resource to the Quality department for data collection, agendas, and committee minutes as requested to include (but not exclusive of) PSQC, Stroke Committee, Core Measures, HCAHPS, RM data.

Collects data and creates reports and documents for other various committees and initiatives as requested.

Assists with the triennial Survey Readiness Assessment (SRA) by LPNT.

Assists the Quality Director in the development and coordination of action plans for identified deficiencies.

Assists in education of hospital leaders and staff based on identified deficiencies.

Other duties as assigned.

Minimum Education

High School Diploma or GED Equivalent is required.

Minimum Work Experience

Previous experience in quality management. Thorough knowledge of regulatory compliance including Joint Commission, CMS, and State Regulatory Compliance.

Statistical data collection, management, and analysis expertise.

Required Skills

Certified Professional in Healthcare Quality (CPHQ), HACP, NAHQ, is preferred.

Requires critical thinking skills, decisive judgment and the ability to work with minimal supervision. Must be able to work in a stressful environment and take appropriate action.

EEOC Statement

Person Memorial Hospital ensures all job applicants and employees have equal employment opportunities. We comply with all applicable laws prohibiting discrimination against an employee or job applicant based on factors such as color, race, sex, age, religion, national origin, disability, genetic information, gender identity, sexual orientation, veteran status, or any other basis protected by federal, state, or local law.