Manager, Ambulatory Regulatory Compliance and Staff Development

Overview: USA Health is Transforming Medicine along the Gulf Coast to care for the unique needs of our community.
USA Health is changing how medical care, education and research impact the health of people who live in Mobile and the surrounding area.
Our team of doctors, advanced care providers, nurses, therapists and researchers provide the region's most advanced medicine at multiple facilities, campuses, clinics and classrooms.
We offer patients convenient access to innovative treatments and advancements that improve the health and overall wellbeing of our community.
Responsibilities: The Manager, Ambulatory Regulatory Compliance and Staff Development, under the direction of the Physician Enterprise Chief Nursing Officer, will be responsible for managing nursing education, professional development, and department compliance of regulatory standards in USA Health Physician Enterprise clinic locations; responsible for coordination and collaboration with the transformation specialists and department leadership, with the goal of promoting high-quality and cohesive clinical education and professional development; coordinates the communication to leadership and management when external surveyors arrive to include an up-to-date contact list used during the survey; collaborates with the department directors and managers regarding plans and activities to stay continuously survey ready; communicates the results of audits and monitors results related to the regulatory requirements of the Joint Commission (TJC) and Center for Medicine and Medicaid Service (CMS) in reportable formats with trend analysis and benchmarks to identify opportunities for improvement; collaborates with the accreditation consultants and Standards Interpretation Group (SIG) to address organizational issues and/or action plans; prepares reports related to the following: National Patient Safety Goals compliance, tracer findings, environmental survey findings, mock survey outcomes, TJC monitoring requirements for post survey, sentinel event alert progress reports, and Root Cause Analysis (RCA) action plans; provides consultation, education, and support to all levels of leadership and staff to accomplish survey readiness goals through practice sessions and tracer activities aimed to increase knowledge and enhance performance level for staff during survey; disseminates TJC and CMS updates to appropriate leadership; informs and collaborates with Health Information Technology to ensure the electronic medical record adheres to TJC and CMS regulatory requirements; collaborates with Staff Development/Quality management to ensure the TJC compliance and National Safety Goals are addressed in the Clinical Resources Fair, Patient Safety Fair, and Health Stream education; constructs tracer assessment tools for patient throughout system and process tracers to assess standards of care and change processes that constitute quality outcomes; identifies and facilitates change processes using Robust Process Improvement (RPI) to uncover specific causes of failure and utilize the Plan, Do, Study, Act (PDSA) Performance Improvement model to direct improvement efforts; researches and stays abreast of news releases, compliance changes, and TJC standards under review for the circulation to leadership, management, staff, and physician on a regular basis; oversee and help with the education needs assessment and the planning, development, organization, implementation, and evaluation of educational activities for front-line staff, including orientation; foster adherence to accreditation and regulatory standards; coordinates the application and maintenance of all Clinical Advancement ladder members; demonstrate regular and prompt attendance with the ability to work the assigned schedule as defined and overtime as required; other related duties as assigned.
Qualifications: bachelor’s degree in nursing from an accredited institution as approved and accepted by the University of South Alabama, four years of directly related experience, and a current Alabama RN license or current multi-state RN license.
Master’s degree in nursing, nursing education, or healthcare administration is preferred.
Experience with Joint Commission/Accreditation survey visits is highly preferred.