RN/RRT Regulatory Program Coordinator- Patient Safety & Quality

Your job is more than a job.
Why a Great Place to Work
At LCMC Health we help you to lean into your calling by leaning in with you, ensuring you have the resources to do your job as only you can.
And that begins with receiving the support you need to thrive and grow, which looks different for each person. Living out our commitment to inclusion requires providing benefits that are as diverse and unique as our workforce. It's a responsibility we take seriously.
Because we don't just serve the New Orleans community-we're at the beating heart of it. Whether by offering community health services or making medical innovations more accessible, LCMC Health is bringing a culture of wellness to the communities that matter to you.
When you know you're making an authentic impact, you give a little extra to every day-as a person, with your team, in your community-and that's one of the reasons why you'll be a perfect fit at LCMC Health, where giving a little something extra is at the heart of everything we do.
The Regulatory Program Coordinator is responsible for organization-wide Regulatory Compliance activities and functions. Implements the functions of the Regulatory Compliance Program and coordinates, facilitates proactive and reactive regulatory efforts. Functions as a multidisciplinary resource person for organizational regulatory preparation for surveys, licensure requirements and hospital representative during surveys.
Job Description
This job description is intended to describe the general nature and level of work performed by employees assigned to this department. This is not an exhaustive list of all duties and responsibilities, and LCMC Health reserves the right to amend and change responsibilities to meet organizational needs as necessary.
GENERAL DUTIES

• Regulatory compliance:
  - Facilitates and promotes the comprehensive system of organization wide compliance with Centers of Medicare/Medicaid Services regulations, laws, Joint Commission Standards, license boards and standards.
  - Collaborates with the leadership to implement, revise, monitor organization policies and procedures regarding regulatory compliance. Works with department leaders to develop, complete and facilitate monitoring to ensure compliance.
  - Assists multidisciplinary personnel and physicians in addressing matters requiring regulatory advisement, in collaboration, with the organization's leadership staff.
• Standards of services:
  - Reviews clinical and non-clinical records to assure compliance with standards of services delivered in the organization and takes steps to assess the risk regarding compliance. Reports critical issues for immediate action and/or administrative action.
  - Collaborates with the departmental leaders to educate staff regarding new or updated standards.
• Audits:
  Performs clinical record audits.
• Reporting and documentation:
  - Compiles reports for the leaders regarding internal and external surveys per defined timeline.
  - Prepares all communication with regulatory bodies.
  - Maintains action plans and files regarding licensure and compliance with state, federal agencies and with accrediting bodies.
• Data collection and analysis:
  - Collects and analyzes data related to the process that support care and treatment. Safety provided patients, visitors, employees, contract staff, physicians, students and volunteers.
  - Collaborates with appropriate team/department to ensure the processes are in place for relevant data collection, identifying high risk areas and educational needs throughout the organization. Collaboratively participates in content development for education.
  - Annually coordinates with the Joint Commission application, Intracycle monitoring assessment and mock surveys. Engages the leadership for completion and review.

EXPERIENCE QUALIFICATIONS

• 3 years Healthcare experience.
• 1 year Previous regulatory/compliance experience.

EDUCATION QUALIFICATIONS

• Bachelor or Associate Degree in Nursing or Respiratory Therapy
• Preferred: Master's Degree

LICENSES AND CERTIFICATIONS

• Certification Name: Registered Nurse (RN) or Registered Respiratory Therapist (RRT)

SKILLS AND ABILITIES

• Adheres to Children's Hospital rules and regulations.
• Maintains standards based on accreditation bodies such as Joint Commission, CMS, etc.
• Maintains continuing education requirements commiserate with position.
• A background in healthcare regulatory compliance is essential.
• Must have extensive knowledge of expectations of various regulatory agencies which govern the principles and practices of patient care.
• In addition, must have skills necessary to develop and implement recommendations to ensure compliance with the local and national standards to meet the requirements for hospital accreditation.
• Computer skills is a necessity.
• The incumbent must have the ability to effectively communicate utilizing written and verbal skills.

REPORTING RELATIONSHIPS

• Does this position formally supervise employees? No

FUNCTIONAL DEMANDS

• Sedentary: Very light physical requirements- Sedentary Work- Exerting up to 10 pounds of force occasionally (occasionally means activity or conditions exist up to 1/3 of the work day), and/or, a negligible amount of force frequently (frequently means activity or condition exists from 1/3 to 2/3 of the work day) to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.

PHYSICAL DEMANDS

• Sitting - Frequent (36-66% of day)
• Standing - Occasional (0-35% of day)
• Walking - Occasional (0-35% of day)
• Reaching forward - Frequent (36-66% of day)
• Wrist position deviation - Occasional (0-35% of day)
• Keyboard use/repetitive motion - Continuous (67-100% of day)
• Talk or hear - Continuous (67-100% of day)

SENSORY REQUIREMENTS

• Near Vision - Accurate 20/40
• Far Vision - Accurate 20/40
• Depth Perception - Accurate
• Hearing - Accurate

OCCUPATIONAL EXPOSURE RISK POTENTIAL

• Bloodborne pathogens - Not Anticipated
• Chemical - Not Anticipated
• Airborne communicable diseases - Not Anticipated
• Extreme temperatures - Not Anticipated
• Radiation - Not Anticipated
• Uneven surfaces or elevations - Not Anticipated
• Extreme noise levels - Not Anticipated
• Dust/particular matter - Not Anticipated
• Other (List) - Not Anticipated

POPULATION SERVED

• Neonate/Infant up to 1 year: No
• Youth (1yr to 15 yrs): No

The above job summary is intended to describe the general nature and level of the work being performed by people assigned to this work. This is not an exhaustive list of all duties and responsibilities. LCMC Health reserves the right to amend and change responsibilities to meet organizational needs as necessary.WORK SHIFT:
Days (United States of America)
LCMC Health is a community.
Our people make health happen. While our NOLA roots run deep, our branches are the vessels that carry our mission of bringing the best possible care to every person and parish in Louisiana and beyond and put a little more heart and soul into healthcare along the way. Celebrating authenticity, originality, equity, inclusion and a little "come on in" attitude is the foundation of LCMC Health's culture of everyday extraordinary
Children's Hospital, at the heart of LCMC Health's incredible community of care, has been the go-to hospital for expert children's health, wellness, and one-of-a-kind care in Louisiana and the Gulf Coast. Learn more about Children's Hospital's 40+ specialties and our national ranking by U.S. News & World Report as a Best Children's Hospital
Your extras

• Deliver healthcare with heart.
• Give people a reason to smile.
• Put a little love in your work.
• Be honest and real, but with compassion.
• Bring some lagniappe into everything you do.
• Forget one-size-fits-all, think one-of-a-kind care.
• See opportunities, not problems - it's all about perspective.
• Cheerlead ideas, differences, and each other.
• Love what makes you, you - because we do

You are welcome here.
LCMC Health is an equal opportunity employer. All qualified applicants receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability status, protected veteran status, or any other characteristic protected by law.
The above job summary is intended to describe the general nature and level of the work being performed by people assigned to this work. This is not an exhaustive list of all duties and responsibilities. LCMC Health reserves the right to amend and change responsibilities to meet organizational needs as necessary.
Simple things make the difference.
1. To get started, take your time to fully and accurately complete the application for employment. Incomplete applications get bogged down and are often eliminated due to missing information.
2. To ensure quality care and service, we may use information on your application to verify your previous employment and background.
3. To keep our career applications up-to-date, applications are inactive after 6 months and, therefore, require a new application for employment to be completed.
4. To expedite the hiring process, proof of citizenship or immigration status will be required to verify your lawful right to work in the United States.