What are the responsibilities and job description for the Regulatory & Quality Specialist position at Shore Medical Center?
Position Summary
Regulatory & Quality Specialist provides administrative support for quality improvement, regulatory, and quality data abstracting procedures. Provides high quality data abstraction and performance improvement services following federal and medical center specifications while maintaining the highest level of confidentiality. Will cross-train to support to Medical Staff Services department if the need arises.
Core Duties and Responsibilities
• Accurately schedules meetings for the departments and prepares daily schedule.
• Enters information into database and prepares monthly statistical reports and other reports as requested.
• Maintain policies and procedures using the hospital designated electronic software program. Functions as program administrator for Policy Manager, manages and assigns policies to staff as appropriate.
• Prepares meeting agenda, meeting packets, meeting minutes, and distributes to departmental staff.
• Applies all HIPAA and PHI standards
• Accurately abstracts organization Quality Measures into QIP- NJ data base, Juvare and NHSN
• Meets all abstraction deadlines.
• Participates in webinars from QIP – NJ other regulatory and performance organizations as they relate to Quality Core Measures or other organizational improvement topics
• Participates in committees and initiatives for organizational quality and performance improvement.
• Assist other departments in chart review and data collection, as time allows
• Regularly assess hospital practices and procedures to identify areas for improvement.
• Assist regular audits and evaluations of hospital departments and processes to ensure adherence to regulatory requirements. Prepare reports on findings and recommend corrective actions as needed.
• Assist training programs for hospital staff regarding Joint Commission standards, compliance procedures, and best practices. Facilitate workshops and seminars to enhance understanding of regulatory requirements.
• Assist with hospital leadership to develop, update, and implement policies and procedures that align with Joint Commission standards and improve patient safety and quality of care.
• Assist preparations for Joint Commission surveys and accreditation processes. Coordinate with various departments to ensure that all necessary documentation and evidence of compliance are in order.
• Keep abreast of changes in regulatory standards and best practices related to Joint Commission accreditation, and inform hospital staff accordingly.
Requirements
• Bachelors degree preferred
• Detail oriented; strong written and communication skills.
• Knowledge of federal and state laws, and regulatory requirements regarding HIPAA.
• Ability to organize, prioritize, and manage multiple projects and ensure completion.
• Demonstrated knowledge of Word Processing and spreadsheets.
• Data abstraction experience.
• Exposure to quality improvement concepts and processes preferred.
• Proficient in Microsoft Office products, industry related core measure abstraction software systems and electronic medical record applications.
• Ability to work independently.
• Ability to taking minutes for meetings.
Additional information
• To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed above are representative of the knowledge, skill, and/or ability required.
• This job description should not be construed as an exhaustive statement of duties, responsibilities or requirements, but a general description of the job. Nothing contained herein restricts the company’s rights to assign or reassign duties and responsibilities to this job at any time.
• Shore Medical Center is an Equal Opportunity Employer. All applicants will receive consideration for employment without regard to sex, affectional or sexual orientation, gender, gender identity, orientation or expression; marital status, domestic partnership status, civil union status, pregnancy, race, creed, ancestry, color, ethnicity, national origin, age, disability, religion, genetic information, or veteran status or any other basis prohibited by law.
