The Regulatory Compliance Coordinator provides operational support and overall coordination for the strategic implementation of Accreditation and Licensing programs. Ensures the hospital and clinics are aligned with Joint Commission and standards established through state and federal regulations. Additionally, facilitates on-going regulatory compliance activities through assignments of extensive rounding on clinical and non-clinical departments.
- In coordination with Director and Administrative Director (VMMC), plans and leads accreditation and licensing program activities for full compliance of the Joint Commission (TJC) accreditation, Washington State Department of Health (DOH), Conditions of Participation (CoPs) and other state and federal standards, rules and regulations in assigned hospitals.
- Identifies regulatory compliance gaps and mentors leadership in developing appropriate plans to address and close the gaps to achieve outcomes, promotes safe practices and achieves sustainable compliance with regulatory standards. Works collaboratively on VMM annual intra-cycle monitoring of compliance with Joint Commission standards with identified opportunities for improvement and corrective action plans.
- Serves as a coach, facilitator, and resource for regulatory program activities.
- Provides consultative services, coaches and facilitates key stakeholders and staff to help mitigate/resolve potential safety, health and environmental issues/deficiencies/violations (within defined scope of responsibility) in accordance with established requirements and hospital policy.
- Administration of Accreditation and Observation tools and techniques, with ability to write and communicate at an executive level (i.e. board reports).
- Schedules and assigns observations throughout the organization. Collects data and reports to escalate information to executive and organizational leaders.
- Develops customized observation tools that cross all Joint Commission and Conditions of Participation rules.
- Supports leadership committees, meeting materials and scheduling.
- Supports organizational departments with disease specific certifications and other state and federal investigations.
- Maintains the organizational profile with the Joint Commission and other annual licensing requirements.
Education: Bachelor's degree required. Master's degree in related field preferred.
Experience: Minimum three years’ experience in Clinical and/or Regulatory Compliance preferred. In-depth understanding of the language of regulatory bodies, and the ability to interpret those to the work areas, required. Demonstrated knowledge of, and skill in performing root-cause analysis, performance improvement techniques, and medical system performance analysis required. Advanced skills in using spreadsheets (e.g., MS Excel), and proficiency with data analyses, required. Strong organizational skills, and aptitude for detail, required. Strong written and verbal communication, interpersonal, and teamwork skills required. Demonstrated presentation skills and experience conducting educational sessions required.
Licenses/Certificates/Registration: Washington State (DOH) Registered Nurse licensure preferred. VMPS certification preferred.
Virginia Mason Memorial, part of the Virginia Mason Health System, is made up of a 226-bed hospital as well as 20+ primary care and specialty care practices/services. We are a nonprofit community hospital that has served Central Washington's Yakima Valley for more than 60 years. We are seeking remarkable employees with a passion for patients and customer service to add to our growing team!
We offer a three-tier benefit plan including medical, dental, vision coverage, plus a generous 401K plan (with matching!), life insurance options, competitive compensation, an employee wellness clinic and leadership development and education.
Why do we do what we do? As the region’s leading health care provider and Yakima’s largest employer, we believe that by improving health, we can transform Yakima! Our vision is to "create healthy communities one person at a time." This means that each member of our award-winning team works to provide our patients, and their families, with the best medical and individual care possible. We work together to demonstrate our values of Respect, Accountability, Teamwork, Stewardship, and Innovation for everyone who walks through our doors, patients and coworkers alike. We would love to hear from you!
“Virginia Mason Memorial provides reasonable accommodations to assist qualified individuals in order to perform the essential duties/requirements their job requires. The description is intended to provide only basic guidelines for meeting job requirements and serves as merely a summary rather than a complete listing of duties. Responsibilities, knowledge, skills, abilities, and working conditions may change as needs evolve. This job description does not constitute a contract as employment is at will.”
Virginia Mason Memorial