Department: Safety, Compliance & Risk Management
Reports to: Director of Quality and Risk Management
Type: Full time
Compliance and Risk Management Analyst
845 Jackson St, San Francisco, CA 94133
About this role
Department: Safety, Compliance & Risk Management
The Compliance and Risk Management Analyst supports the efforts of the Director of Quality and Risk Management and VP of Medical Staff, Quality and Compliance. With strong organizational skills, the Compliance/Risk Management Analyst assists the Safety, Compliance & Risk Management Department in achieving its goals and objectives; identifies and resolves a variety of issues related to regulatory issues; maintains basic regulatory files; develops and facilitates training and training materials; and prepares and submits requirements to federal and state regulators. This person has direct, daily contact with Chinese Hospital managers and staff.
Essential Duties and Responsibilities
- Assist with tracking, reviewing and analyzing regulatory requirements, including new statutes and regulations and impacting all areas of the organization to ensure compliant implementation of the newly passed regulation.
- Assists and supports Compliance with regulatory change review and works with business areas to ensure regulatory changes have been applied correctly.
- Manage all aspects of accreditation, regulatory and hospital licensure compliance across the organization.
- Supports VP of Medical Staff, Quality and Compliance in responding to events by developing written planning documents, preparing and delivering presentations, conducting in depth analyses in the areas of risk and compliance.
- Identifies opportunities for improvements based on evidence based practices in regulatory and accreditation and corporate compliance, analysis of internal and external compliance/risk assessments and findings from regulatory authorities.
- Leverages experience in accreditation and regulatory survey processes and builds upon current knowledge of requirements related to CMS Conditions of Participation, The Joint Commission, and the California Department of Public Health.
- Develops and delivers education and quality assurance processes regarding internally and externally driven trends in healthcare risk management and regulatory compliance.
- Assists managers and staff with workflow development, policy and procedure review/revision, mock survey assessments, and ongoing education.
- Partners with operational leaders and relevant support departments e.g. Patient Safety, Infection Control, to develop corrective action plans and to track the success of corrective actions
- Assist with ensuring implementation of a robust communication and education program related to readiness activities including tracer activities, survey methods and processes, results of compliance assessment activities, and methods of compliance for problematic and high-priority requirements
- Assist in the coordination FMEA process projects
- Follows Hospital and Department policies and procedures at all times, including but not limited to: Administrative Manual, Environment of Care, Human Resources, Infection Control, Corporate Compliance, Code of Ethics, etc.
- Attend, actively participate and complete in-services, training classes, mandatory classes, seminars/workshops, staff meetings, exercises and drills; reads all department communication and assigned materials.
- Customer Service – Provides excellent customer service and shows compassion to all patients, visitors and co-workers. Seeks feedback to ensure all needs are met. Anticipates and recognizes the concerns of others, even if those concerns are not openly expressed.
- Communication – Keeps manager and team informed of progress, problems, development and plans. Gets along and interacts positively with co-workers and others.
- Accepts and performs other duties as assigned.
- Bachelor’s degree in a work-related discipline/field from an accredited college or university, preferred
- 3 years+ of healthcare experience in compliance, risk management and safety, quality and regulatory surveys
- Must be knowledgeable with TJC/CMS/Title 22 regulatory standards as well as compliance, quality and performance improvement concepts
- Effective communication skills
- Computer proficiency (Microsoft Office) (EMR knowledge a plus)
- Ability to work effectively with individuals at all levels and with varying backgrounds both within and outside the organization
- Ability to plan, organize, and prioritize multiple tasks and work independently to meet deadlines and exercise sound professional judgment
While performing the duties of this job, staff is regularly required to sit, stand, walk, talk and/or listen. He/she uses his/her hands to do computer work, write reports, do equipment set-up/cleaning/storage, clerical support, etc. He/she will be using the phone frequently. Good vision is needed to be able to read schedules, enter accurate data, etc. He/she must have good general health and demonstrate emotional stability so as to carry out the above-enumerated duties.
- Able to lift up to 30 pounds
- Use proper body mechanics when handling equipment
- Standing, walking and moving 50% of the day
Complies with Chinese Hospital Compliance Handbook including Code of Ethics and all statutes, regulations, guidelines applicable to federal and state programs. Responsibilities include, following the guidelines and reporting suspected violations of any statute, regulations, agreements or guidelines applicable to all healthcare programs.