Website Orlando Health
Orlando Health is seeking a Regulatory Consultant – to function as a consultant to Orlando Health in the area of healthcare accreditation regulations, standards, and clinical performance improvement. Clinical background with experience in a hospital setting is preferred. Experience in Surgical/Perioperative, OB/Perinatal/or Critical Care is a plus. Openings available at multiple locations including Winnie Palmer Hospital, Corporate and Bayfront Health St. Petersburg.
- Communicates directly with The Joint Commission (TJC) account executive or Standards Interpretation Group for clarification of standards or requirements.
- Educates organization leadership and medical staff on changes to accreditation /regulatory requirements.
- Develops and maintains effective working relationship with the medical and operations staff.
- Performs mock surveys to evaluate compliance with The Joint Commission/CMS standards and requirements.
- Provides oversight for Orlando Health Patient Care Policies and Procedures and compliance with
- Directs improving compliance with and understanding of all healthcare regulations and standards.
- Maintains reasonably regular, punctual attendance consistent with Orlando Health policies, the ADA, FMLA and other federal, state and local standards.
- Mentors and provides guidance for the development of educational opportunities for the organization relative to standards and accreditation regulations.
- Develops tracer tools or other specific focus tools for use in mock survey process or evaluation of compliance with specific regulatory/accreditation/ certification requirements.
- Responsible for completion of components of The Joint Commission application for submission of required data and documentation.
- Actively performs audits to evaluate compliance on regulatory requirements.
- Trains additional identified team members to perform focused mock surveys using specific tracer tools.
- Facilitates development of action plans with nursing unit leaders to
- In conjunction with site leadership, actively facilitates site Regulatory Council to support ongoing TJC readiness and sustainability.
- Works with Orlando Health’s leaders to communicate mock and actual survey findings and directs the completion of corrective action plans to address deficiencies.
- Directs development and maintenance of unit based medical record review data base. Analyzes data, interprets results.
- Coordinates external body regulatory/accreditation surveys for the organization.
- Directs development and implementation of action plans to address non-compliance.
- Provides regulatory guidance and support to medical staff and operations leaders /councils pursuing specific TJC certifications.
- Assists internal customers with performance improvement initiatives which support the Strategic
Qualification & Experience:
- Five (5) years of clinical or related experience, including experience in healthcare quality/performance improvement projects.
- If Allied Health professional, maintain license with Florida Department of Health as appropriate for profession.
- Bachelor’s degree in healthcare, nursing, allied health or closely related field.
- If RN, maintain license with Florida Department of Health – renewed biannually
Company: Orlando Health
Vacancy Type: Full Time
Job Location: Jacksonville, FL, US
Application Deadline: N/A