Overview

 USA Health is Transforming Medicine along the Gulf Coast to care for the unique needs of our community. 

USA Health is changing how medical care, education and research impact the health of people who live in Mobile and the surrounding area. Our team of doctors, advanced care providers, nurses, therapists and researchers provide the region's most advanced medicine at multiple facilities, campuses, clinics and classrooms. We offer patients convenient access to innovative treatments and advancements that improve the health and overall wellbeing of our community.

Responsibilities

The Director, Clinical Compliance and Regulatory Services is responsible to the System ACNO for Clinical Compliance & Regulatory services for providing leadership to help fulfill the University of South Alabama's mission and vision and assure regulatory compliance related to professional licensure, reporting of abuse allegations, drug diversion Investigations, policy development, regulatory Investigations, State and Federal Regulations and The Joint Commission Standards; the individual in this position demonstrates leadership, motivation, initiative and creativity in addressing regulatory services issues throughout the health system and utilizes effective communication skills; the System Regulatory Services Director initiates and maintains ongoing oversight and collaboration with other employees/departments/areas related directly or indirectly to maintain compliance with regulatory services requirements; provides leadership and participates in activities throughout USA health to achieve and maintain clinical compliance with Federal and State regulations and The Joint Commission standards; maintains knowledge of new regulations and standards; facilitates the incorporation of regulations and standards Into policies, practices, and processes; through assessments and utilization of the tracer methodology, leads Regulatory Compliance Mangers in preparing USA Health for Joint Commission accreditation and disease-specific certifications, CMS validation and program specific certifications, service line designations of excellence and other program specific certifications or accreditations. Facilitates activities during on-site survey activities through active participation in survey and reporting of findings; participates in the development, implementation, and submission of corrective action plans related to areas of clinical non-compliance; provides leadership to USA Health staff to ensure professional licensure requirements are current; communicate and coordinate With Clinical Managers any work restrictions related to non-compliant professional licensure/registration; collaborates with the system Clinical compliance Auditor/Data Analyst to maintain current, accurate licensure and national certification data; promotes an environment conducive to patient safety by identifying investigating and reporting areas of regulatory vulnerability and risk; collaborates with others throughout USA Health to resolve patient safety issues; participates in the review and investigation of allegations and events requiring possible external regulatory reporting and preps reports for submission to outside agencies as needed; optimize the use of reports and functionality of available technology to prevent and identify medication diversion in the various medication use processes. Participates in the Investigation process of suspected medication diversion Incidents; perform analysis of medication dispenses, administration, and documentation to determine trends of performance outside of hospital policies and nursing standards of practice with Administration, Clinical Management, Human Resources, and the USA Health CNO for mandatory reporting to Alabama Professional Boards; compile and submit subpoenaed documents as required; develop educational activities related to medication diversion and the potential consequences and legal implications; collaborates with the System Clinical Compliance Auditor/Data Analyst to develop and maintain a reporting database for medication compliance, identify trends & opportunities for improvement, and to prevent medication diversion; assists in the provision/oversight in the development and revision of USA Health policies and nursing operational guidelines that incorporate regulatory and nursing practice standards; participates in the review and investigation of regulatory agency complaints; assists in the preparation of reports for outside agencies as to ensure compliance with submission requirements; leads and participates in initiatives, including educational programs, as related to Regulatory Services and patient safety; serves as consultant regarding regulatory services compliance for USA Health staff; participates in professional activities related to regulatory service issues; assumes responsibility for self-directed professional growth; maintain knowledge and understanding of State and Federal regulations; attends in-services, workshops, seminars, and meetings to keep abreast of current patient care practices, regulations and standards; maintains expertise through continuing education programs and through formal and informal practice. Shares knowledge with colleagues as mentor and consultant; provides administrative support to committees, such as Nursing Congress, Evidence-Based Committees, and APP Leadership Council.

Qualifications

Bachelor's degree in nursing or a healthcare related field from an accredited institution as approved and accepted by the University of South Alabama and five years of professional clinical nursing experience, and current licensure with the state Of Alabama as a registered nurse. Experience in pediatric/women's health preferred. Experience developing and overseeing policies and procedures as well as managing Advanced Practice Providers is preferred. A master's degree in nursing or a related field is highly preferred.