Manager, Policy and Procedure Compliance- Nursing Education- University Hospital

Overview

USA Health is Transforming Medicine along the Gulf Coast to care for the unique needs of our community. USA Health is changing how medical care, education and research impact the health of people who live in Mobile and the surrounding area. Our team of doctors, advanced care providers, nurses, therapists and researchers provide the region's most advanced medicine at multiple facilities, campuses, clinics and classrooms. We offer patients convenient access to innovative treatments and advancements that improve the health and overall wellbeing of our community.

Responsibilities

This position will provide leadership and work in partnership across USA Health to evaluate and analyze areas of compliance risk, formulate risk mitigation, and ensure compliance with USA Health policies and procedures and applicable federal and state law; this position will be responsible for conducting audits evaluating policy compliance levels and recommend improvements; it is responsible for ensuring periodic risk assessments are prepared for all applicable areas related to policy compliance and that key policy compliance elements are monitored and audited regularly; collaborates with department heads, staff, and stakeholders to identify potential policy compliance risks within USA Health and to improve and establish policy and procedure processes; researches, creates and modifies policies based on evidence-based guidelines, CMS regulations and Joint Commission, state/federal law, and other regulatory standards; Monitors and conducts regular audits to ensure compliance with policies regarding regulatory requirements, best practice, standards of care; Reviews and assesses operations, clinical processes, and other areas to identify areas of non-compliance regarding policies and procedures; develops and implements strategies and actions plans based on audits to address deficiencies regarding policy and procedure regarding standards of care, best practice, Joint Commission standards, CMS guidelines and state/federal law within USA Health policies and procedures; identifies and analyzes potential risks to regulatory compliance regarding policy and procedure; provides recommendations, guidance, and works with relevant stakeholders to implement corrective actions as needed; prepares detailed reports on risk assessments, audit findings, and recommendations. Communicates findings, audit reports and recommendations to management, senior management and key stakeholders; maintains comprehensive documentation of audit processes, results, and actions taken regarding policy and procedure. Stays abreast of standards of care and best practices and emerging risks in healthcare; maintains professional and technical knowledge by attending educational workshops, reviewing professional publications, and establishing a network of regulatory and compliance professionals; provides training and education to USA Health staff on policy and procedure compliance requirements; fosters accountability, and continuous improvement; collaborates with multi-disciplinary teams across USA Health to ensure effective policies and procedures are implemented; Provides education and orientation to new managers regarding the USA Health policy management system. Performs all functions required of the Site Administrator for the USA Health policy management system. Regular and prompt attendance; ability to work schedule as defined and overtime as required; related duties as required.

Qualifications

Bachelor’s degree in nursing or a related healthcare field from an accredited institution as approved and accepted by the University of South Alabama, three years of policy review or policy management experience, and current licensure with the state of Alabama in the clinical field of study. Masters degree preferred.