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SoutheastHEALTH Regulatory Compliance Coordinator in Cape Girardeau, Missouri

Regulatory Compliance Coordinator

Clinical Professional
Cape Girardeau, Missouri

Quality Management Full-Time



Day ShiftResponsible for all regulatory compliance functions i.e. Joint Commission standard updates/reviews/accreditation, CMS concerns and any other surveying bodyBegin

  • Responsible for coordinating and escorting all regulatory surveys/surveyors

  • Attend appropriate meetings to assist with regulatory compliance including but not limited to Patient Safety Committee, Regulatory Compliance Task Force

  • Monitor the following websites and/or mailings regarding updates, new guidelines, new regulations, etc and distribute changes as appropriate:

  • The Joint Commission

  • Hospitals-Fast Track

  • Home Care-Fast Track

  • Center for Medicare and Medicaid Services

  • Rules of the Missouri Department of Health and Senior Services

  • Other websites/publications as appropriate

  • Create monitoring tools, assist with collection, and report results from patient tracers, observation monitoring, or other data necessary to meet regulations.

  • Maintain the following:

  • Plan of Response to Unannounced Survey from TJC, state, etc

  • Patient Tracer Tools

  • In coordination with the Executive Director of Quality Management assist with the timely completion & electronic submission of The Joint Commission (lab, disease spec. care, hospital, home care), Evidence of Standards Compliance report(s), Measure of Success data, Electronic-Statement of Conditions, and Clarifications as needed or required

  • Develop and distribute National Patient Safety Goal Posters for house-wide education and display

  • Develop and distribute the Regulatory Newsletter

  • Create & Develop educational tools for department directors/nurse managers to use in educating staff of regulatory compliance

  • Coordinate with The Joint Commission Chapter leaders the completion of the Intracycle Monitoring & update as appropriate annually

  • Work in coordination with Patient Safety Officer and Director of Facilities Management as needed

  • Perform other duties as assigned


  • Healthcare related degree, RN preferred

  • Experience in a hospital or health care setting preferred

  • Knowledge of medical terminology and hospital routines

  • Experience working with Microsoft Office including Word, PowerPoint, Access and Excel is preferred

  • Must be able to read, write and speak English