Accreditation & Clinical Compliance Consultant

Accreditation & Clinical Compliance Consultant
US-OR-Portland Job ID: 21-16820 Type: Regular Full-TimeSystem Office 1919 Building Overview
At Legacy, we strive every day to make life better for others.

Accreditation and regulatory clinical compliance reflect our commitment to quality healthcare.

Your ability to research, interpret and provide consultation to support these requirements will ensure our readiness.

If you want to grow your skills with a healthcare community that values your unique strengths and capabilities, we invite you to consider this opportunity.

Consider joining our small team of dedicated clinical compliance professionals at Legacy Health.

Responsibilities
Leads ACC projects and tasks as directed by the ACC Manager to ensure work progresses on schedule and to specified performance objectives.

Provides consultation services to stakeholders regarding complex regulatory and accreditation challenges and strategizes to ensure ongoing clinical compliance and survey readiness.

Co-leads system-level multidisciplinary teams in complex compliance efforts (with limited manager oversight).

Exercises excellent interpersonal skills and judgment in communicating with and involving relevant stakeholders in all aspects of work.

Consistently delivers high-quality work within agreed-upon time frames.

Specifically, the ACC Consultant contributes to the ACC Team’s support of LH clinical compliance efforts by contributing the following:

Knowledge and Expertise

Maintains knowledge of and conducts ongoing interpretation of regulatory requirements and accreditation standards (e.g.

Centers for Medicare and Medicaid Services (CMS), state departments of health, and The Joint Commission (TJC).

Provides consultation to stakeholders regarding existing and proposed regulatory requirements and standards.

Provides guidance in efforts to design/amend processes to comply.

Guidance includes a developing skill of synthesizing consideration of LH policy, culture, documentation environment and risk tolerance.

Consultation and Influence

Works with senior clients to define scope of work, objectives, deliverables and timeframes to achieve compliant processes at both a site and system level.

Serves as assertive yet graceful liaison in both verbal and written documentation with external and internal stakeholders in efforts toward compliant processes.

Provides consultation regarding high-risk areas and helps develop options to address them.

Collaborates with and influences operational managers to resolve continued non-compliance with standards.

Understands the LH medical record documentation process and administrative/clinical standards environment.

Applies this knowledge toward identifying, referring, and problem-solving opportunities for standardization and improvement to increase compliance levels.

Effectively advances a culture of accountability toward compliance with policies and standards.

System Level Facilitation

Provides direction across entities to ensure consistency in interpretation and enforcement of policies and procedures.

Provides leadership related to monitoring and coaching of care providers related thereto.

Recommends key strategic planning to define and propose creative approaches to resolve compliance issues

Site Level Consultation

Co-sponsors (with the Chief Administrative Officer) the site level compliance committee.

Works in conjunction with Chief Administrative Officers, Nurse Executives, and committee chairs to prioritize and manage portfolio of preparedness activities.

Supports regulatory compliance efforts at the site level by participating on and/or reporting at Quality Council, Leadership Council, and/or Medical Staff Committees, as requested by leadership.

Facilitates discussion of compliance findings and the development of effective action plans that align with Legacy Health strategic goals.

Provides direct support to LH organizations during visits by regulators and surveyors.

Provides direction to clients completing annual self-assessment, conducting mandated performance data collection, and formulating and implementing tailored and practical compliance plans.

Effectively synthesizes data into clear summary documents to support problem identification, improvement work, and decision-making.

External Regulatory/Accreditation Organization Communication

Serves as a Legacy Health liaison to regulatory and external agencies working on compliance initiatives, as requested.

Represents Legacy Health in a professional manner and seeks to build positive working relationships with the healthcare community.

Pursues relationships with regulatory and accreditation officials to secure timely advice regarding challenging compliance areas and survey/investigation concerns.

Qualifications
Education:

Bachelor’s degree or equivalent experience required.

Juris Doctor or Master’s degree with related major coursework in business administration, public administration, healthcare administration or nursing strongly preferred.

Experience:

A minimum of three years of applicable health care and/or regulatory compliance experience.

Skills:

Knowledge of and ability to identify, comprehend, interpret and consult regarding regulatory and accreditation requirements for LH organizations

Ability to synthesize complex and evolving regulatory issues

Strong written and verbal communication skills, including as applied to official regulatory correspondence

Solid project management, planning, and implementation skills

Excellent interpersonal skills necessary to present and communicate important information effectively to all levels of leadership

Keyboard skills and ability to navigate electronic systems applicable to job functions

Ability to contribute as an effective member of the ACC Team to provide consultation and organizational planning that meets LH’s clinical compliance needs

LEGACY’S VALUES IN ACTION:

Follows guidelines set forth in Legacy’s Values in Action

Equal Opportunity Employer/Vet/Disabled

PI

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