Quality Patient & Safety Advisor – Regulatory Compliance

Cape Cod Healthcare Inc.; Hyannis (MA); On-site; USD 90,000 - 110,000; Full time

Job summary

Cape Cod Hospital seeks a Peer Review RN to develop, implement and facilitate processes for peer review of cases, track data and maintain files to ensure care delivered meets standards. The role provides consultative support to medical/legal affairs and leadership, applying clinical judgment to review plans of care and escalate concerns.

Responsibilities include regulatory readiness, mock surveys, document reviews and coordination with departmental leaders.

Qualifications

• Graduate of a school of nursing.
• BSN preferred.
• Three years perioperative/procedural nursing experience.
• Ability to work independently, prioritize work activities, and use time efficiently.
• Must possess excellent English usage, grammar, punctuation, and style.

Responsibilities

• Develop and facilitate peer review processes for case analysis.
• Track data and maintain regulatory files.
• Provide consultative guidance to medical/legal affairs and leadership.
• Interpret regulatory updates and ensure readiness for surveys and audits.
• Coordinate mock surveys, tracer activities, and chart reviews.

Skills

Communication skills

Time management

Regulatory knowledge

Education

BSN

Tools

EHR systems

Job description

Purpose of Position: The Peer Review RN is responsible for the development, implementation and facilitation of processes related to the peer review of cases, tracking and trending of data and maintenance of appropriate files to determine whether appropriate care was delivered in accordance with the Medical Staff Constitution, Medical Staff General Rules, accreditation, regulatory and licensing requirements. The Peer Review RN applies clinical expertise and independent judgment in analyzing patient cases, identifying and pursuing presenting issues and facilitating monthly case presentations. This role leans on clinical background to review plans of care delivery, identifying and escalating potential concerns and providing consultative services and guidance to medical/legal affairs and departmental/divisional leadership as needed.

Description

Regulatory Compliance and Readiness

• Monitor compliance with applicable regulatory requirements, accreditation standards, and organizational policies affecting procedural services.
• Interpret and communicate relevant regulatory updates from the Centers for Medicare & Medicaid Services (CMS), Mass Health, DPH, The Joint Commission, CDC, and other applicable regulatory agencies.
• Maintain current knowledge of regulatory standards related to procedural areas, including pre-procedure assessments, informed consent, patient identification, time-outs, medication management, infection prevention, discharge planning, and medical record documentation.
• Coordinate regulatory readiness activities, including mock surveys, tracer activities, document reviews, and departmental assessments.
• Maintain regulatory compliance records, supporting documentation, and evidence of corrective actions.
• Assist departmental leaders in preparing for regulatory surveys, accreditation visits, and external audits.
• Make clinical judgments based on evidence-based standards of care, review criteria and nursing practice guidelines when applicable
• Utilize electronic health information imaging when appropriate

Regulatory

• Monitor compliance to applicable regulatory and accreditation/certification program requirements including PRO/PM measures and the Joint Commission DSC certifications.
• Manage surgical related registries including BCBS for total joint replacement and spine surgery.

Qualifications

EDUCATION/EXPERIENCE/TRAINING

• Graduate of a school of nursing
• (BSN) – A Bachelor of Science in Nursing
• Three years prior nursing experience in perioperative or procedural areas
• Must be able to work independently, prioritize work activities, and use time efficiently.
• Must be able to maintain confidentiality.
• Must be able to demonstrate and promote a positive team-oriented environment.
• Must be able to stay focused and concentrate under normal or heavy distractions.
• Must be able to work well under pressure and/or stressful conditions.
• Must possess the ability to manage change, delays, or unexpected events appropriately
• Must have strong knowledge of medical terminology, anatomy and physiology, medications, and laboratory values.
• Must be able to operate a general computer, fax, copier, scanner, and telephone.
• Must be knowledgeable of multiple software programs, including but not limited to Microsoft Word, Outlook, Excel, and the Internet.
• Must possess excellent skills in English usage, grammar, punctuation, and style.
• Ability to follow instructions and respond to upper management’s directions accurately.
• Demonstrates accuracy and thoroughness. Looks for ways to improve and promote quality and monitors own work to ensure quality is met.

• Must demonstrate exceptional communication skills by conveying necessary information accurately, listening effectively, and asking questions where clarification is needed.
• Job requires long periods of time working on a computer

Schedule Details:

4 Day Work Week, Monday-Thursday, No Weekends, & No Holidays Organization : Cape Cod Hospital

Primary Location : Massachusetts-Hyannis

Department : CCH-Quality / Patient Safety

Annual/Hourly: Unassigned

Hiring Pay Range: 0 - 0