Washington University is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, age, sex, sexual orientation, gender identity or expression, national origin, genetic information, disability, or protected veteran status.
This position is full-time and works approximately 40 hours per week.
Department Name/Job Location:
This position is in the Department of Faculty Practice Plan. This position is for the Medical School Campus.
Position will be responsible for the development and sustainment of centralized policies at the Faculty Practice Plan (FPP) level and oversight of regulatory compliance/ accreditation, primarily in the ambulatory care setting, in collaboration with all Washington University School of Medicine Clinical Departments. This position requires an individual who is experienced and thrives on program development from early concepts to full implementation; this position also requires professional confidence as a largely independent and self-sustaining staff contributor and as a process and change leader.
PRIMARY DUTIES AND RESPONSIBILITIES:
Supports exceptional clinical outcomes and patient safety using knowledge of all regulatory body and state licensure standards and/or regulations; uses tracer, audit and tracking tools to monitor all CMS Conditions of Participation and other regulatory requirement standards on a rotating basis throughout the year; identifies areas of high risk for more intense monitoring and intervention.
Responds to inquiries by regulatory and accreditation bodies; Works collaboratively with hospital partners to assist with inquiries by regulatory and accrediting bodies when both parties are involved.
Develops and monitors implementation of policies, procedures, and regulatory plans within all Washington University School of Medicine Clinical Departments.
Reviews available quality and patient safety data to identify areas of high risk for deviation from standard and need for policy implementation; develops action plans to correct deficiencies through policy implementation or modification as appropriate implementation and monitoring of those plans.
Conducts debriefs and root cause analyses in collaboration with WUSM Clinical Departments on known departures from CMS COPs and other standards, with development and monitoring of appropriate action plans.
Works collaboratively through-out organization to educate clinical leaders on changes in standards and policies; incorporates changes into the regulatory compliance/ accreditation program.
In coordination with the Patient Safety & Quality staff, monitors opportunities for improvement and sentinel event reports to focus on high risk areas that may negatively impact standards compliance.
Develops and maintains a continuous readiness program that encompasses all the necessary elements to maintain regulatory compliance; reviews the integrity of the program over time, reporting concerns and barriers to compliance to leadership.
Participates in rounding to engage with caregivers and front line staff responsible for meeting standards and policy compliance.
Coordinates regulatory and survey activity (i.e. CMS, state and/or mock survey activity).
Maintains a working knowledge of emerging regulatory and accreditation initiatives across Washington University School of Medicine and develops close working relationships with their program/clinical representatives.
Assists with WUSM Patient Safety, Quality and Performance Improvement initiatives as needed, at the direction of FPP leadership.
Bachelor’s degree in a healthcare-related field; current RN licensure in the state of Missouri preferred.
Knowledge of state and federal regulations specific to healthcare compliance and/or accreditation.
RN licensure preferred.
Master’s degree, or 5 to 10 years of relevant work experience.
Current RN licensure in the state of Missouri preferred.
Experience in program development in quality measurement and/or improvement or patient safety and/or compliance/ accreditation.
Experience working in large, complex healthcare organization; certification in the area of healthcare compliance or accreditation.
Superior data management and analytic skills; superior organizational and interpersonal skills, very strong Microsoft Office skills, including Excel, PowerPoint, and Word.
Ability to design, develop, and present refined spreadsheets, reports, white papers, and slide presentations; confidence and comfort in working in a largely independent role
Strong project management skills with experience in planning, facilitating, and organizing improvement teams; extreme degree of professionalism, discretion, and confidentiality. comfort interacting with and publicly presenting to with a broad array of administrative and clinical staff, including senior management; experience with performance improvement methods, including statistical concepts, applications and data collection.
Certified Joint Commission Professional (CJCP) certification highly preferred.
Knowledge of Joint Commision Standards.
The hiring range for this position is commensurate with education and experience.
-Retirement Savings Plan -22 vacation days -8 Paid Holidays -Sick Time -Tuition benefits for employee, spouse and dependent children -Free Metro Link/ Bus pass -Free Life Insurance -Health, Dental, Vision -Health Savings Accounts (HSA) -Long Term Disability Insurance -Flex Spending Plan -Other Benefits
Med School HR website (medschoolhr.wustl.edu)
Internal Applicant Instruction:
This position is grade S26.
Please attach a copy of your most current signed performance evaluation (completed within the last 18 months) to your online account. If you have not received a performance evaluation, you may provide two current signed letters of recommendation (written within the last 18 months), preferably to include one letter from either a current or recent former supervisor. To attach these documents, go to: My Career Tools, Add Attachment, Attachment Type – Performance Reviews or Letters of Recommendation.
Washington University in St. Louis, a medium-sized, independent university, is dedicated to challenging its faculty and students alike to seek new knowledge and greater understanding of an ever-changing, multicultural world. The University offers more than 90 programs and almost 1,500 courses leading to bachelor's, master's and doctoral degrees in a broad spectrum of traditional and interdisciplinary fields, with additional opportunities for minor concentrations and individualized programs. The faculty is composed of scholars, scientists, artists and members of the learned professions. They serve society by teaching; by adding to the store of human art, creativity, understanding, and wisdom; and by providing direct services, such as health care.