Hospital Compliance Nurse

Job Title

Compliance and Clinical Monitoring in Assigned Programs

Assists in the preparation for DMH, Joint Commission, Alabama Department of Public Health, Medicaid, HRSA, etc. site surveys

Assists in the AltaPointe policy and procedure review process in assigned programs.

Assists in developing action plans and plans for improvement for standard deficiencies cited during surveys.

Coordinates and performs risk management review process for organization's programs and external providers.

Effectively assist with monitoring and compiling reports to present to the Performance Improvement Sub-Committee meetings as related to assigned programs.

Provides technical assistance to Performance Improvement work groups and monitors compliance with documentation standards in assigned programs.

Collects Performance Improvement Indicators from designated staff, prepares report, and submits data to the Chief Nursing Officer on a quarterly basis or as indicated

Effectively monitors and demonstrates the analysis of RL Solutions data and reports on identified trends and patterns such as medication errors and employee, consumer infection rates in assigned programs.

Assists with Root Cause Analysis (RCA) as indicated and makes reports to Performance Improvement Committee as it relates to clinical documentation.

Conducts one-on-one training for clinical staff and providers as directed by Chief Nursing Officer.

Research and identify best practices for clinical record documentation and makes recommendations to the Chief Nursing Officer.

Complies with federal, state, and local legal requirements by studying existing and new legislation; enforcing adherence to requirements; advising management on needed actions.

Monitor and report HIPAA privacy or security incidents, ensuring timely documentation and regulatory compliance.

Updates job knowledge by participating in educational opportunities; reading professional publications.

Supervision and Consultation

Seeks supervision and consultation as needed.

Accepts and employs suggestions for improvement.

Actively works to enhance skills.

Courteous and respectful towards patients, visitors and co-workers

Treats patients with care, dignity and compassion.

Respects consumer's privacy and confidentiality.

Is pleasant and cooperative with others.

Assist patients and visitors as needed.

Personal values don't inhibit ability to relate and care for others.

Is sensitive to the consumer's needs, expectations and individual differences.

Is gentle and calm with patients, families and others as appropriate.

Administrative and Other Related Duties as assigned:

Actively participates in Performance Improvement activities

Actively participates in AH committees as requested

Completes assigned tasks in a timely manner

Follows AH policies and procedures

Maintains current license and requirements for renewals (i.e. CEU's), if applicable, and attends regular workshops and in-services

Qualifications

Current RN license to practice in the state of Alabama. BSN or MSN preferred. Minimum of five years of experience in nursing within a medical setting. Current Basic Life Support (BLS) certification. Strong working knowledge of Microsoft Office (Outlook, Excel, Word, etc.). Knowledge of regulatory compliance standards to include The Joint Commission, Alabama Department of Mental Health and Substance Abuse, Medicaid, CMS, HRSA, ABON, and Alabama Board of Medical Examiners outlined below, to be attained within (6) six months of employment:

Knowledge of clinical documentation requirements for inpatient, residential, and outpatient programs

General knowledge of billing standards and practices

Knowledge of monitoring agencies standards (JC, DMH, CMS, Medicaid, Medicare, HRSA, etc.)

Knowledge and utilization of tools to monitor clinical compliance

Knowledge of organization policy and procedures