Regulatory Compliance Coordinator (RN)

at University of Maryland Medical Center
Published August 13, 2022
Location Glen Burnie, MD
Category Default  
Job Type Full-time  


What You Will Do:

Regulatory Compliance Coordinator (RN)
UM Baltimore Washington Medical Center
Full-Time - Day
Glen Burnie, Maryland

The Power of Caring
Within all of us there is untold power. An unstoppable strength. A desire to do more.

At University of Maryland Baltimore Washington Medical Center, we know that caring can't be taught, it's something that comes naturally.

We're looking for talented professionals to join our extraordinary Professional Team at UM Baltimore Washington Medical Center - named Top Workplace in the Baltimore area by The Baltimore Sun two years in a row (2019 & 2020); Named Top Workplace in the USA for 2021!

As part of the acclaimed University of Maryland Medical System, our facility is one of three ANCC Pathway to Excellence designated hospitals in Maryland and features one of the state's busiest emergency departments, as well as a team of experts who care for our community and one another. As a Top 10 Maryland hospital ranked by U.S. News and World Report, UM BWMC is the pulse that keeps Anne Arundel County moving forward.

Job Summary:
Under limited supervision, ensures organizational compliance with quality measures and other performance indicators required by regulatory and accrediting entities. Provides input into establishing goals, objectives and performance standards. Ensures compliance with UMMC policies, quality standards, The Joint Commission, Center for Medicare and Medicaid Services (CMS) Conditions of Participation (CoPs) and Department of Health and Mental Hygiene (DHMH) regulations and codes.

Principal Responsibilities and Tasks:
The following statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all job duties performed by personnel so classified.

  • Provides leadership and/or assistance with hospital-wide activities to evaluate and improve adherence to the Joint Commission accreditation standards, CMS Conditions of Participation, and MD State regulations in preparation for all surveys.
    • Assists with preparation and participates in organizational visits from accrediting agencies.
    • Participates in survey command center activities which may include but is not limited to: keeping track of and fulfilling surveyor requests for environmental logs, policies and procedures, employee files, contracts, etc., responding to emails and phone calls.
    • Assists and participates in organization-wide Joint Commission readiness activities including tracers; monitoring and educating staff in regulatory compliance and hospital policy requirements.
    • Enters tracer data into accreditation tracking tool; reports from these data are provided to staff to use in staff education and improving compliance with Joint Commission standards and CMS Conditions of Participation (COPs).
    • Assists with internal regulatory assessments to evaluate and validate compliance with current standards set forth by various external regulatory agencies.
    • Abstracts data to evaluate medical center's compliance with Joint Commission standards and CMS Conditions of Participation (COPs).
    • Monitors action plan progress in response to external audits and surveys through concurrent and retrospective chart review.
    • Works with providers to monitor and promote quality improvement activities related to regulatory requirements and clinical documentation in the medical record.
    • Participates in Epic UDCs to assure documentation elements are properly embedded in the EHR to meet regulatory standards and conditions of participation.
    • May assist in State and Federal Quality projects to obtain comparative data on quality and regulatory indicators.
    • Attends hospital based committee meetings as assigned.
  • Plans, organizes, and directs activities centered on hospital compliance with the Joint Commission, CMS and other external regulatory entities.
    • Responds, in writing, to complaints from regulatory entities.
    • Monitors complaint/regulatory related action plans and follow-up as necessary.
    • Leads and/or facilitate Root Cause Analysis and Failure Modes Effects Analysis Activities.
    • Coordinates all regulatory activities as assigned.
    • Ensures compliance with established quality measures.
    • Assures data quality, reliability and validity; compiles and enters data into designated data base.
    • Analyzes data to identify opportunities for improving organization's performance.
    • Keeps staff up-to-date with on-going changes in documentation requirements..
    • Provides regular feedback to staff and provides support as requested in quality & safety activities.
    • May facilitate development of department level quality initiatives.
  • As a member of our team, you'll experience:

    • A supportive and collaborative work environment.
    • A comprehensive benefits package including health, vision and dental coverage including prescription drug coverage - Tax-Free Savings Plans, Tuition Reimbursement and more!
    • Work Life Balance: You'll accrue annual leave; we offer dependent care reimbursement, short/long term disability and an employee assistance program.
    • Growth & Educational Assistance: We support your continuing education and career advancement by offering tuition reimbursement & continuing education options.

    What You Need to Be Successful:

    • Associate's Degree in Nursing is required. BSN preferred.
    • Licensure by the Maryland State Board of Nursing Examiners is required.
    • Three (3) years of progressively responsible professional experience, performing quality and/or regulatory compliance review or equivalent is required.
    • Current experience in collecting and submitting externally reported quality data is preferred.
    • Knowledge of Accreditation standards, CMS CoPs, and state regulatory standards preferred.
    • General knowledge of Root Cause Analysis and Failure Modes Effects Analysis preferred.
    • Demonstrate expertise in the use of data, data validation and production of reports.
    • Demonstrate the ability to effectively navigate computer applications for use in abstracting needed data.
    • Demonstrates the ability to effectively navigate external databases which publicly report quality data and to retrieve and/or input data.
    • Highly effective oral and written communication skills are required to work with all levels of hospital personnel, administrators and clinical staff as well as outside agencies.
    • Self-motivated, independent thinker.
    • Working knowledge of Microsoft word, excel and, power point.

    To be immediately considered for this position please contact Dominique Spann at [Click Here to Email Your Resumé] with an updated resume or schedule a call here!

    We are an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to sex, gender identity, sexual orientation, race, color, religion, national origin, disability, protected veteran status, age, or any other characteristic protected by law.