Hospital Compliance Nurse

Compliance and clinical monitoring in assigned programs

• Assists in the preparation for DMH, Joint Commission, Alabama Department of Public Health, Medicaid, HRSA, etc. site surveys
• Assists in the AltaPointe policy and procedure review process in assigned programs.
• Assists in developing action plans and plans for improvement for standard deficiencies cited during surveys.
• Coordinates and performs risk management review process for organization’s programs and external providers.
• Effectively assist with monitoring and compiling reports to present to the Performance Improvement Sub-Committee meetings as related to assigned programs.
• Provides technical assistance to Performance Improvement work groups and monitors compliance with documentation standards in assigned programs.
• Collects Performance Improvement Indicators from designated staff, prepares report, and submits data to the Chief Nursing Officer on a quarterly basis or as indicated
• Effectively monitors and demonstrates the analysis of RL Solutions data and reports on identified trends and patterns such as medication errors and employee, consumer infection rates in assigned programs.
• Assists with Root Cause Analysis (RCA) as indicated and makes reports to Performance Improvement Committee as it relates to clinical documentation.
• Conducts one-on-one training for clinical staff and providers as directed by Chief Nursing Officer.
• Research and identify best practices for clinical record documentation and makes recommendations to the Chief Nursing Officer.
• Complies with federal, state, and local legal requirements by studying existing and new legislation; enforcing adherence to requirements; advising management on needed actions.
• Monitor and report HIPAA privacy or security incidents, ensuring timely documentation and regulatory compliance.
• Updates job knowledge by participating in educational opportunities; reading professional publications.

• Seeks supervision and consultation as needed.
• Accepts and employs suggestions for improvement.
• Actively works to enhance skills.

• Treats patients with care, dignity and compassion.
• Respects consumer’s privacy and confidentiality.
• Is pleasant and cooperative with others.
• Assist patients and visitors as needed.
• Personal values don’t inhibit ability to relate and care for others.
• Is sensitive to the consumer’s needs, expectations and individual differences.
• Is gentle and calm with patients, families and others as appropriate.

• Actively participates in Performance Improvement activities
• Actively participates in AH committees as requested
• Completes assigned tasks in a timely manner
• Follows AH policies and procedures
• Maintains current license and requirements for renewals (i.e. CEU’s), if applicable, and attends regular workshops and in-services

Current RN license to practice in the state of Alabama. BSN or MSN preferred. Minimum of five years of experience in nursing within a medical setting. Current Basic Life Support (BLS) certification. Strong working knowledge of Microsoft Office (Outlook, Excel, Word, etc.).

• Knowledge of clinical documentation requirements for inpatient, residential, and outpatient programs
• General knowledge of billing standards and practices
• Knowledge of monitoring agencies standards (JC, DMH, CMS, Medicaid, Medicare, HRSA, etc.)
• Knowledge and utilization of tools to monitor clinical compliance
• Knowledge of organization policy and procedures