Regulatory and Accreditation Analyst

Interested in a career with both meaning and growth? Whether your abilities are in direct patient care or one of the many other areas of healthcare administration and support, everyone at Parkland works together to fulfill our mission: the health and well-being of individuals and communities entrusted to our care. By joining Parkland, you become part of a diverse healthcare legacy that's served our community for more than 125 years. Put your skills to work with us, seek opportunities to learn and join a talented team where patient care is more than a job. It's our passion.

Primary Purpose

The Regulatory and Accreditation Analyst under the guidance and instruction of the Director of the Regulatory & Accreditation Affairs, partners with organizational leaders in all care settings across the enterprise (inpatient, ambulatory and Correctional Health) to ensure regulatory compliance with state and federal regulations, The Joint Commission (TJC), and other healthcare-related governing and accrediting bodies. This role involves actively facilitating activities related to system-wide surveys (onsite and virtual surveys, mock surveys, and consultations) and serving as an internal consultant and facilitator to maintain regulatory accreditation, certification, and licensure. Reviews and interprets relevant standards and conducts regulatory compliance assessments to identify gaps and areas for improvement while fostering a culture of continuous survey readiness within the organization. Facilitates maintenance of regulations and standards serving primarily as a facilitator and secondarily in an advisor role.

Minimum Specifications

Education

• Must have a Bachelor's degree in a healthcare or related field.
• Prefer a Master's degree in a nursing or healthcare related field.

Experience

• Must have three years of professional experience in regulatory and accreditation, compliance, healthcare, or nursing setting.
• Organization, written, communication, and presentation skills.

Equivalent Education and/or Experience

• May have an equivalent combination of education and experience to substitute for both the education and the experience requirements.
• Experience in highly complex systems may compensate for the years of formal experience listed above.

Certification/Registration/Licensure

• RNs Only: Must have current RN license or valid temporary permit with the Texas Board of Nursing; or valid Compact RN license.

Skills or Special Abilities

• Knowledgeable about the Centers for Medicaid & Medicare (CMS), Health & Human Services Commission (HHSC), Texas Administrative Code (TAC) Rules and Regulations and all accrediting standards related to The Joint Commission (TJC), the Texas Commission on Jail Health and all current disease and/or service line specific accreditation programs where Parkland Health participates.
• Demonstrate the ability to respond to regulatory inquiries and survey activities.
• Demonstrate the ability to coordinate the house-wide tracer program.
• Demonstrate the ability to prepare and respond to regulatory and accreditation surveys; some of which may be unscheduled.
• Demonstrate the ability to coordinate reporting to TJC, HHSC, CMS, and other regulatory bodies.
• Participate in the development of the plan of correction (hospital, correctional health, service line and/or disease specific), as required by regulatory and accreditation bodies.
• Demonstrate effective oral and written communication skills.
• Demonstrate effective analytical skills and techniques.
• Demonstrate ability to analyze, interpret and articulate tracer data.
• Written and presentation skills, and personal computer skills including but not limited to MS Project, MS Word, PowerPoint, Access, and Excel software.
• Communicate effectively with all levels of internal and external customers on complex topics.
• Excellent interpersonal skills and willingness to communicate with all levels of the organization, demonstrating cross-functional collaboration.
• Demonstrate the ability to influence and drive impactful change across various domains, including customer interactions, operational processes, project management, and service activities.
• Demonstrate the ability to adapt to changing priorities with a positive and energetic attitude.
• Able to work individually and as a team and demonstrate self-initiative to seek out opportunities to learn and grow.
• Demonstrate ability to create and maintain organized, confidential, and professionally documented files consistent with department processes.

Responsibilities

1. Maintain knowledge of applicable federal and state rules, regulations, policies and procedures, laws, and guidelines that impact all areas under Parkland Health's licenses and accreditation portfolio.
2. Identify effective internal controls designed to promote adherence to applicable federal and state laws, accreditation agency requirements. Seeks advice and guidance as necessary to ensure proper understanding.
3. Manage survey readiness activities by performing gap analysis of standards, preparing survey documents, scheduling meetings, prepping key stakeholders for sessions, communication, and organizing logistics of the upcoming survey.
4. Coordinate preparations for the surveyor arrival (onsite or virtual) of both announced and unannounced regulatory surveys. This includes communicate to the organization, facilitates surveyor entrance conference, fulfill survey requests, coordinate interviews (workforce or patient) and electronic health reviews,
5. Monitor ever-changing regulations and notify organizational leaders about regulatory updates by reviewing TJC, HHSC, and CMS regulations, and assist with implementation.
6. Serve as a facilitator, advisor or collaborator for system-wide and program-specific accreditations, certifications, and licensures.
7. Provide recommendations on certification activities and collaborate with key stakeholders to prepare for survey activities, identify opportunities for improvement, and develop plans of correction to mitigate risks. Monitors progress for improvements with local leadership to drive change and close gaps.
8. Facilitate and conduct internal regulatory compliance audits and reviews through the system-wide tracer program, analyze data, identifies gaps and opportunities for improvement, partner with key stakeholders to develop plans of correction, and monitor plans of correction for effectiveness and sustainability. Communicates and provides feedback to key stakeholders on audit results.
9. Serve on various system-wide interdisciplinary committees and cross-functional teams as assigned.
10. Stay abreast of the latest developments and trends in regulatory and accreditation by attending seminars and workshops, reading professional journals, and actively participating in professional organizations. Integrates knowledge acquired into current work practices.
11. Educate the workforce on regulatory and accreditation standards through various meetings, committees, and in-services as needed or requested.
12. Collaborate with system-wide leaders to develop, implement, and improve compliance with the organization's policies and procedures.
13. Utilizes the High Reliability Universal Skills when gathering information and changes about processes across the organization. Supports system-wide initiatives by being focused on attention to details, communicating clearly, speaking up for safety, critically thinking, and compliance.
14. Identifies and escalates significant events through appropriate channels across the health system.
15. Execute complaint investigation activities, communicate to the organization, facilitates surveyor entrance conference, fulfill survey requests, coordinate interviews (workforce or patient) and electronic health reviews, If the complaint is substantiated, collaborate with key stakeholders to address gaps and to develop plans of correction.
16. Contribute to the design of work processes and operating procedures within the department, implementing changes to improve effectiveness, productivity, and efficiency in alignment with the department's and Parkland Health's overall goals.
17. Provide detailed written descriptions of reportable events for review by the Sr Regulatory and Accreditation Analyst and Director of Regulatory and Accreditation before submission to the applicable agencies.
18. Assume various assigned special projects, ensuring timely and effective completion.

Job Accountabilities

1. Identifies ways to improve work processes and improve customer satisfaction. Makes recommendations to supervisor, implements, and monitors results as appropriate in support of the overall goals of the department and Parkland.
2. Stays abreast of the latest developments, advancements, and trends in the field by attending seminars/workshops, reading professional journals, actively participating in professional organizations, and/or maintaining certification or licensure. Integrates knowledge gained into current work practices.
3. Maintains knowledge of applicable rules, regulations, policies, laws, and guidelines that impact the area. Develops effective internal controls designed to promote adherence with applicable laws, accreditation agency requirements, and federal, state, and private health plans. Seeks advice and guidance as needed to ensure proper understanding.

Parkland Health and Hospital System prohibits discrimination based on age (40 or over), race, color, religion, sex (including pregnancy), sexual orientation, gender identity, gender expression, genetic information, disability, national origin, marital status, political belief, or veteran status.As part of our commitment to our patients and employees' wellness, Parkland Health is a tobacco and smoke-free campus.