Policy and Procedure Manager

Position Summary:

Under the supervision of the Performance Improvement Administrator, directs, coordinates, plans, and manages the corporate electronic policy management system while adhering to the guiding principles of the Corporate Napartet Strategies and Angyaq Quality System.

This professional serves as the point of contact for document management across the organization and is responsible for assisting with the development, implementation, and maintenance of corporation policies and procedures, standard operating procedures, forms, and other documents that ensure compliance with regulatory standards, improve quality of care, and enhance patient safety.

Position Responsibilities:

A.    Essential Functions

•         Documentation and Record-Keeping: Maintaining an organized policy management system to ensure easy access and up-to-date documents for staff operations. The coordinator works cross-functionally with clinical and administrative departments to supports document readiness for audits and surveys.

•         Monitoring and Evaluation: Regularly reviewing documents to ensure they are processing through the electronic policy management system correctly and in a timely manner. Monitoring expiration dates and approval paths. Assessing the document effectiveness and compliance, assisting with necessary revisions based on feedback from staff, needed process improvement, or changes in regulations, laws, requirements, or practice standards. Facilitate collaborative Policy Committee meetings.

•         Interdepartmental Collaboration: Collaborating with stakeholders to draft new documents and revise existing documents ensuring they reflect the needs and operations of the entire organization.

•         Policy Development: Collaborating with clinical and administrative staff to create and update hospital policies and procedures, standard operating procedures, forms, and other documents, going forward known as “documents”, based on best practices, legal requirements, and organizational goals. Ensuring consistent formatting, language, template and approval path utilization.

•         Developing Training and Education: Providing training and resources to staff on the utilization of the electronic policy management system, TJC, CMS, HRSA, CHAP, CAP, OSHA, and other applicable regulatory standards and requirements. This may involve organizing workshops, creating training materials, conducting presentations, or arranging one-on-one assistance. Communicate policy changes to leadership.

•         Regulatory Compliance: Reviewing corporate documents for content reference to local, state, and federal regulations as well as accreditation standards from bodies such as, but not limited to, The Joint Commission (TJC), Centers for Medicare & Medicaid Services (CMS), Health Resources and Services Administration (HRSA), Community Health Aid Program (CHAP), College of American Pathologists (CAP), and Occupational Safety and Health Administration (OSHA). Monitoring changes in healthcare regulations and advise management on necessary document updates.

•         Quality Improvement: Working with quality improvement teams to align documents with initiatives aimed at enhancing patient care and safety. Participating in quality assurance activities and contributing to hospital-wide performance improvement initiatives.

Benefits Include:

• Generous PTO – starting at 4.5 weeks per year, accrued over time
• Eleven paid holidays
• Comprehensive healthcare coverage
• Life and Disability Insurance
• Flexible Spending Account
• Retirement plans
• Employee Wellness Center
• Plus More!

C#