What are the responsibilities and job description for the Regulatory and Patient Safety Specialist position at Good Shepherd Rehabilitation Network?
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JOB SUMMARY
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The Regulatory and Patient Safety Specialist is responsible for supporting the organization’s regulatory compliance, patient safety initiatives, and medical affairs. Key duties include promoting compliance with federal, state, and local regulations; maintaining readiness for regulatory surveys; collecting and analyzing patient safety data; and coordinating corrective action tracking.
Additionally, the Regulatory and Patient Safety Specialist oversees functions within Medical Affairs, which include—but are not limited to—credentialing, privileging, and reviewing staff bylaws and accreditation standards.
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ESSENTIAL FUNCTIONS
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Policy Implementation & Regulatory Compliance:
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Implement and maintain organizational policies related to regulatory compliance and patient safety.
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Monitor and interpret relevant healthcare regulations (CMS, The Joint Commission, state/local laws).
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Collaborate with leadership to ensure policies align with current standards and best practices.
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Regulatory Survey Readiness:
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Prepare for and support internal and external regulatory surveys and audits.
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Coordinate survey readiness activities, including documentation review and compliance checks.
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Participate in mock surveys and maintain survey readiness across departments.
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Patient Safety & Event Reporting:
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Assist with investigation and analysis of patient safety events, near misses, and adverse outcomes.
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Assist with conducting root cause analyses and trend reviews to support quality improvement efforts.
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Promote a culture of safety and collaborate with teams to implement improvements.
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Corrective Action Monitoring:
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Track implementation and completion of corrective and preventive action plans (CAPAs).
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Maintain documentation and report on progress to leadership and relevant committees.
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Identify gaps in compliance and escalate issues as needed.
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Data Collection & Reporting:
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Collect, validate, and analyze data on safety events, outcomes, and compliance indicators.
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Develop reports and dashboards to communicate findings and trends.
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Support performance improvement initiatives based on data insights.
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Medical Affairs Functions:
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Manage credentialing and recredentialing processes for medical staff and allied health professionals.
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Verify practitioner qualifications, training, licensure, and malpractice history in accordance with regulatory standards and medical staff bylaws.
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Maintain accurate and current credentialing records and databases (e.g., MSOW, MD-Staff, or other platforms).
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Facilitate medical staff privileging and ensure compliance with delineation of privileges and scope of practice.
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Coordinate medical staff meetings, committee agendas, and minutes.
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Ensure adherence to Medical Staff Bylaws, Rules & Regulations, and accreditation requirements.
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Serve as a liaison between the medical staff, administration, and quality departments.
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QUALIFICATIONS:
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To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
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Education
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Bachelor’s degree in Healthcare Administration, Nursing, Therapy, or a related field required.
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Work Experience
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Minimum of 1 - 3 years of experience in healthcare quality, regulatory compliance, patient safety, or medical staff services preferred.
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Licenses / Certifications
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Licensed as a clinical healthcare professional in Pennsylvania required.
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Working Conditions
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A hybrid work both from a remote location and at designated onsite facilities, based on operational needs and project requirements.
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Office and healthcare environment.
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Occasional extended hours during survey preparation or credentialing cycles.
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May require occasional travel between facilities.
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