Regulatory Accreditation Data Specialist

OU Medicine; United States; On-site; USD 70,000 - 95,000; Full time

Benefits offered by this job

PTO

401(k)

Medical & dental plans

Job summary

OU Health is seeking a Regulatory Accreditation Data Specialist to oversee the Patient Safety Evaluation System (PSES) and related risk management activities. You will analyze safety events, support risk mitigation, and ensure survey readiness across OU Health facilities.

Responsibilities include managing CMS rounding tools, building weekly dashboards, and coordinating Environment of Care compliance initiatives with clinical and support teams.

Qualifications

• Bachelor's Degree required.
• Three (3) years of relevant administrative experience required.

Responsibilities

• Monitor and investigate safety reports involving patients, staff, and visitors.
• Identify critical events and escalation to Clinical Risk Program Manager.
• Track and trend data on near misses, adverse events, and incidents.
• Provide education and resources on patient safety and risk management.
• Collaborate with departments to promote safe practices.
• Administer CMS rounding and Compliance Connect software systems.
• Monitor regulatory changes and implement committee recommendations.
• Oversees Environment of Care compliance and related audits.

Skills

Organizational skills

Verbal communication

Written communication

Excel

PowerPoint

Power BI

Salesforce

Critical thinking

Independent work

Confidentiality

Education

Bachelor's degree

Tools

Excel

Word

PowerPoint

PowerBI

Salesforce

Job description

Position Title: Regulatory Accreditation Data Specialist

Department: Patient Safety & Regulatory Accreditation

Job Description

General Description: Under general direction, works within the Department of Patient Safety & Regulatory Accreditation to independently facilitate and oversee projects at OU Health facilities. Responsible for managing the Patient Safety Evaluation System (PSES), analyzing safety events, and supporting risk mitigation efforts. Environment of Care (EOC) compliance projects and survey readiness projects as assigned by the leadership team.

Essential Responsibilities

• Monitor and investigate safety reports involving patients, staff, and visitors.
• Identify critical events and escalation to Clinical Risk Program Manager.
• Track and trend data on near misses, adverse events, and incidents.
• Provide education and resources on patient safety and risk management.
• Collaborate with departments to promote safe practices.
• Administer CMS rounding and Compliance Connect software systems.
• Monitor regulatory changes and implement committee recommendations.
• Oversees Performance Improvement Process related to Environment of Care compliance.
• Develops and distributes Environment of Care compliance tools to managers, directors, and staff for continuous survey readiness.
• Coordinates multidisciplinary Environment of Care rounds.
• Build weekly dashboards for the rounds in “CMS rounding” software.
• Ensure that each finding has documented follow up and completion by the involved unit directors.
• Conduct compliance audits to ensure sustainability with the action plans.
• Serves as a liaison between OUH and regulatory agencies during on-site survey activity.
• Oversees logistics for recruiting and training guides/scribes, scheduling conference rooms, and ensuring surveyors are scheduled to speak with OUH staff.
• Serve as Administrator for Facilities Survey Inc “CMS Rounding” software.
• Build and maintain audit question sets and tie to regulatory standard.
• Collaborates with Life Safety leadership to ensure the software build meets all needs.
• Monitors upcoming and released new standards, regulations, and CMS Conditions of Participation.
• Collaborates with appropriate staff to implement EOC Committee recommendations.
• Assists the department with education initiatives, including Regulatory Bootcamp, as required by applicable regulations.
• Drafts regulatory documents such as corrective action plans, newsletters, and other educational resources.
• Serves as Administrator for OUH Regulatory Auditing system utilizing software system.
• Updates leadership mapping and escalates Regulatory issues to the administrative team as appropriate.
• Assists in scheduling events via Microsoft Outlook.

General Responsibilities

Performs other duties as assigned.

Minimum Qualifications

• Education: Bachelor's Degree required.
• Experience: Three (3) years of relevant administrative experience required.
• License(s)/Certification(s)/Registrations(s): None.

Knowledge, Skills, and Abilities

• Advanced organizational and planning skills.
• Advanced verbal and written communications skills.
• Proficiency in Excel, Word, PowerPoint, PowerBI, and Salesforce.
• Ability to maintain effective working relationships during stressful conditions.
• Ability to maintain confidentiality of information.
• Ability to work independently and demonstrate good decision-making skills.
• Advanced critical thinking skills.

Benefits

• We offer a comprehensive benefits package, including PTO, 401(k), medical and dental plans, and many more.

OU Health is an equal opportunity employer.

We know that a total benefits and compensation package, designed to meet your specific needs both inside and outside of the work environment, create peace of mind for you and your family.

OU Health is the state’s only comprehensive academic health system of hospitals, clinics and centers of excellence.

With 11,000 employees and more than 1,300 physicians and advanced practice providers, OU Health is home to Oklahoma’s largest doctor network with a complete range of specialty care.

OU Health serves Oklahoma and the region with the state’s only freestanding children’s hospital, the only National Cancer Institute-Designated OU Health Stephenson Cancer Center, Oklahoma’s flagship hospital, which serves as the state’s only Level 1 trauma center and Edmond Medical Center in the heart of the Edmond Community.

Becker’s Hospital Review named University of Oklahoma Medical Center one of the 100 Great Hospitals in America for 2020.

OU Health’s oncology program at OU Health Stephenson Cancer Center was named Oklahoma’s top facility for cancer care by U.S. News & World Report in its 2020-21 rankings.

OU Health also was ranked by U.S. News & World Report as high performing in these specialties: Colon Surgery, COPD and Congestive Heart Failure.

OU Health’s mission is to lead healthcare in patient care, education and research.

Experts in prevention, treatment and cures, our team works to improve lives through innovation in medical care, education and research, while investing in the people, technologies and facilities that will enable us to achieve our goals.

We are seeking individuals who have a passion and talent for caring for others.

By joining our team, you will provide quality health care to our community through the work you do every day.

We provide clinical and non‑clinical opportunities to further your career and we invite you to explore our available positions.

Equal employment opportunities are provided to all employees and applicants for employment without regard to race, color, religion, gender, national origin, age, disability, sexual orientation, gender identity, genetic information or protected veteran status in accordance with applicable federal laws. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, placement, promotion, termination, layoff, transfer, leaves of absence, compensation, and training. Reasonable accommodations are made to the known physical and mental limitations of qualified individuals with disabilities.