The regulatory function is vital in making safe and effective healthcare products available worldwide. Individuals who ensure regulatory compliance and prepare submissions, as well as those whose main job function is clinical affairs or quality assurance are all considered regulatory professionals.
One of our most valuable contributions to the profession is the Regulatory Code of Ethics. The Code of Ethics provides regulatory professionals with core values that hold them to the highest standards of professional conduct.
Like all professions, regulatory is based on a shared set of competencies. The Regulatory Competency Framework describes the essential elements of what is required of regulatory professionals at four major career and professional levels.
Join the brightest minds in regulatory at the annual Regulatory Convergence. See the global regulatory community in action. Intensive workshops. Topical sessions. Meet ups with regulators. This is where it all comes together.
SUMMARY: Serves as the institutional expert on the Merit-Based Incentive Payment System (MIPS) for Eligible Clinicians (EC), and the Meaningful Use (MU) program for Eligible Hospitals (EH). Manages Direct Messaging communications and registers ECs on the Centers for Medicare/Medicaid Services (CMS) website for attestation. Responsible for enterprise-wide patient safety plan. Responsible to eliminate or reduce the incidence and severity of harm/loss to patients, families, staff and the organization. Responsible for the Event Reporting System. Upon request, assists the Director of Quality & Regulations in administrative duties and assigned projects.
ESSENTIAL DUTIES AND RESPONSIBILITIES: include the following:
Develops, monitors and reports activities to improve patient safety (focusing on NQF Safe Practices, HACs, and IHI and AHRQ indicators). Responsible for patient safety standards in the applicable accreditation survey, state licensure regulations and federal conditions of participation.
Serves as patient safety subject matter expert and serves as a member of the High Reliability Team. Functions as process improvement team leader/member to reduce hospital acquired conditions, injuries, errors, and unintended outcomes. This expertise is provided in various venues as appropriate or assigned.
Administers and implements the TFHD Event Reporting system, including review of safety, behavioral, and disruptive events by staff and providers. Provides operational guidance and training to all staff. Monitors and escalates issues to appropriate Director/Manager and other members of the leadership team.
Identifies and implements patient safety best practice initiatives by reviewing sentinel event alerts, Patient Safety Organization information, and other key organizations and references. Participates in event analysis and case reviews.
Coordinates Beta HEART program initiative, including annual Culture of Safety Survey. Compiles survey results and assists with plans for improvement with Director/Manager/Supervisor of each department.
Reviews care and treatment provided by staff and providers as part of the peer review or other event analysis processes.
Assists with regulatory compliance, accreditation and State survey process through staff education and survey preparedness rounds.
Coordinates and implements all Meaningful Use and MIPS reporting requirements, including but not limited to:
Data gathering and submission for all components of the MIPS program
Collaboration with clinical information systems to ensure current and future stages of MIPS are built appropriately into the system for end-user utilization by participating in the build, test and data collection in the EHR
Attestations on behalf of all eligible clinicians and providers.
Assists with the development of the MIPS workflows and with adoption, reporting, and achievement of quality measures within established timelines.
Maintaining project documentation including detailed records of attestations and submissions, attends team meetings, participates in learning opportunities, and provides issue resolution
Participation in project teams and activities relating to the Meaningful Use and MIPS projects.
Assisting leadership in developing overall Meaningful Use MIPS strategy and tactical plan; provide key status reporting and continued evolution of MACRA/MIPS requirements to leadership.
Understands how MIPS programs work, including staying abreast of program changes as they are proposed and finalized; serve as the point of knowledge regarding MACRA, MIPS, and the QPP for the organization; responds to and provides appropriate information for all electronic data-related questions and inquiries; provides end-user education and training
Works with Clinical Quality Initiatives on projects combining Health IT and Quality Improvement. Serves as liaison with California and/or Nevada Departments of Public Health and other registries to accomplish and report MU and MIPS measures.
Prepares and submits summary reports of MIPS and Patient Safety activities, including payments, to the Medical Staff Quality Committee, Board Quality Committee, and Board of Directors as assigned
Represents the department on appropriate committees as assigned.
Ensures compliance with HFAP, CMS and all other Federal, State and regulatory agencies.
Maintains a clean and safe working environment.
Demonstrates System Values in performance and behavior.
Complies with System policies and procedures.
Other duties as may be assigned.
QUALIFICATIONS: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
No supervisory responsibilities
Required: Current California RN License or commensurate clinical license
Preferred: Certified Professional in Patient Safety (CPPS) certification
Preferred: Green belt or lean certification
EDUCATION AND EXPERIENCE:
Required: Minimum of five (5) years' clinical experience
Strong technical knowledge and an understanding of data elements and data manipulation. Strong analytical and problem solving skills and a strong attention to detail. Ability to produce analysis of basic quality measure reporting. Ability to converse knowledgably with physicians.
Internal Number: Q & R
About Tahoe Forest Health System
Tahoe Forest Hospital is a not-for-profit rural health care facility and designated critical access hospital. It is fully accredited by the Healthcare Accreditation Facilities Program and licensed by the State of California Department of Health Services.
Tahoe Forest Hospital has 25 acute care beds and 36 long-term care beds. Our service area covers six rural counties, two states and approximately 3,500 square miles, reaching the communities of Truckee, North Lake Tahoe, Donner Summit, the Sierra Valley in California, and Incline Village in Nevada.