Director of Compliance RN Full Time - Rehab Hospital of Northern Arizona
Company: Vibra Healthcare
Location: Flagstaff
Posted on: January 12, 2021
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Job Description:
Organization Vibra & ErnestRehabilitation Hospital of Northern
Arizona is seeking a--Director of Compliance - RN ---to join our
team!The Director of Compliance provides clinical leadership for
the following areas: Infection Prevention/Control, Medical Staff
Services, Regulatory Compliance, Risk Management, and Quality
Management/Improvement. Integrates the hospital's mission and
"Guiding Principles" into daily practice.Essential Functions:*
Oversight of and implementation of the Infection Prevention &
Control Program. Demonstrates and maintains knowledge of infection
prevention and control processes utilizing CDC as the basis of this
knowledge. Completes an annual risk assessment, annual evaluation
of program effectiveness, plan update, and develops quality
measures as indicated. * Collaborates with the medical staff
regarding functions related to medical staff privileging and
credentialing, performance improvement measurements, professional
practice evaluation development and reviews, and aggregation by
practitioners. Reports the results to the medical staff
leadership.* Facilitates the hospital performance improvement
program through the collaboration with other hospital leaders.
Provides guidance regarding measurements, data collection,
analysis, conclusions, and process improvement. Ensures that the
teams and committees meet as required by Federal, State, and local
requirements, as well as within the needs of hospital operations
and inclusive of performance improvement teams, FMEA teams, other
teams, and committee meetings.* Implements and manages risk
management functions including incident reporting, investigational
follow up, grievances, root cause analysis, provides notices of
potential claims, and litigation management in conjunction with
senior leadership. Reviews legal medical record requests and
provides recommendations regarding the potential of litigation risk
to management. * Ensures submission of data to internal and
external databases, as required by accreditation and regulatory
agencies, is submitted timely and accurately. Communicates with
external referral agencies regarding community acquired infections
and reports required infections to health departments.* Educates
Medical Staff and hospital employees during initial orientation,
re-orientation, and as education in area of expertise as
indicated.* Facilitates compliance for the facility for related to
CMS, The Joint Commission, and State/Federal regulations. Completes
audits to identify ongoing compliance.* Prepares Medical Staff,
hospital and hospital staff for survey activities by regulatory and
accrediting agencies. Drafts survey responses to regulatory and
accreditation agencies.* As part of leadership, provides expertise
and supports the facility operations.Qualifications:* Registered
Nurse OR a combination of a Bachelor's Degree in a biological
science and APIC (Association for Professionals in Infection
Control and Epidemiology) Certification required* Minimum four
years clinical experience preferred* Two years in clinical
compliance role preferredAdditional Qualifications/Skills:*
Knowledge of and resource for Federal, State and the Joint
Commission standards and hospital specific rules and regulations.*
Knowledge of clinical operations and procedures.* Ability to
maintain quality, safety, and/or infection control standards.*
Demonstrates general computer skills including: data entry, word
processing, email, and record management.* Demonstrates critical
thinking skills: Using logic and reasoning to identify the
strengths and weaknesses of alternative solutions, conclusions or
approaches to problems.* Effective organizational and time
management skills.* Effective written and verbal communication
skills.* Ability to maintain proper levels of confidentiality.*
Ability to work closely and professionally with others.Our
recruitment team wants to get to know you. Share your passion!
Please complete our online application and submit your resume for
immediate consideration.If selected, our interview process includes
phone interviews, in person interviews, and several vetting
tools.Thank you for taking the time to consider a career
opportunity with our hospital.
Keywords: Vibra Healthcare, Flagstaff , Director of Compliance RN Full Time - Rehab Hospital of Northern Arizona, Executive , Flagstaff, Arizona
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