Regulatory Compliance Coordinator

POSITION SUMMARY  

This position is responsible for monitoring and analyzing current and impending regulations and standards, and conducting and facilitating internal and external audits. The Regulatory Compliance Coordinator will assist with the development and implementation of Corrective and Preventive action (CAPA) plans and conducting Effectiveness Checks. Assists with ensuring compliance to state, federal and accrediting agency regulations, and standards as well as South Florida Donor Network, Inc. (SFDN)’s standard operating procedures (SOPs).  This position is also responsible for technical development of personnel, leading others through audits, ensuring audit deliverables, and maintaining the quality management software audit, asset, and supplier programs. The Regulatory Compliance Coordinator will assist with the equipment program and validation activities for equipment, applicable software verification, and any other validation and qualification tasks.   

ESSENTIAL FUNCTIONS  

Essential Functions Statement(s):  

• Responsible for conducting internal audits per the established audit schedule to ensure SFDN’s compliance to all state, federal, and accrediting agency regulations and standards and SFDN’s SOPs, and assisting with conducting and facilitating external audits.  
• Identify processes for audit, to include: 
• those required by regulatory bodies or accrediting agencies. 
• processes having undergone significant revision. 
• effectiveness assessments of corrective and preventive action plans. 
• those processes with a significant number of failure points. 
• SFDN’s regulatory and accrediting agency audit CAPA responses. 
• Assist the Manager of Quality & Regulatory Affairs (MQRA) with developing an annual audit schedule.  
• Ensures audits (self-assessments) required by accrediting bodies are completed within prescribed time frames. 
• Conducts audits in accordance to established SOPs ensuring: 
• Audits are scheduled, conducted, and documented within the quality management software audit program including the initiation of an occurrence report for all audit findings. 
• Use of audit assessment checklists which will assess compliance of written policy against regulation and current practice against written policy. 
• Audit reports are written and provided to SFDN’s Leadership and Management 
• Timely receipt and closure of CAPA responses 
• Effectiveness checks are performed to ensure ongoing compliance with the implemented CAPAs  
• Serves as a resource for the development of corrective actions to address observations and findings. 
• Assist the MQRA with preparing for and facilitating external audits in accordance with established SOPs. 
• Audits are initiated, conducted, and documented within the quality management software audit module, including the initiation of an occurrence reports for all audit findings. 
• Assist with the development and completion of regulatory and accrediting agency gap assessment tools 
• Meet with respective department management and staff to collaboratively complete gap assessments 
• Assist with addressing all gaps identified to ensure SFDN’s establishes compliance 
• Responsible for monitoring and analyzing changes in legislation and accreditation standards that affect SFDN’s operations, including, but not limited to, those of CMS, UNOS, ASHI. 
• Performs monitoring, review, and ensures completion of vendor or supplier qualifications required for compliance with regulatory and accrediting agencies. Will recommend actions for vendors or suppliers that do not maintain compliance requirements or have a high complaint and/or occurrence rate. 
• Responsible for assisting the MQRA with maintaining the supplier program in the quality management software, ensuring all vendors are entered accurately, categorized, and all relevant documentation (qualification surveys, licenses, registrations, etc.) is attached. 
• Maintains all existing licensure or registrations ensuring they are current.  Assists the MQRA with new applications for licensure or registration including, and not limited to, the completion of re-accreditation applications and pre-inspection checklists. 
• Work with Quality & Regulatory Affairs staff to ensure completion of donor record audits, DRAI recording audits, and authorization recording audits. Assist the MQRA and MQRA with ensuring these audits meet both the needs of the department and are conducted in a manner which ensures regulatory compliance of documentation of the donation event. 
• Track and trend audit findings to assist departmental management in identifying opportunities for improvement (OFIs). 
• Initiates and participates in PDSAs and other quality improvement projects. 
• Will assist with validation activities for new equipment, re-qualification of existing equipment, software verification, etc. to include written validation protocols, written validation reports, and re-qualification or addendum reports when required. 
• Responsible for assisting the MQRA with the monitoring asset program in the quality management software to ensure SFDN’s equipment files are accurate and that all maintenance, calibrations, cleaning, etc. are completed as required.  
• Conducts audits to ensure SFDN maintains compliance with the established equipment program. 
• As needed, assists the Quality & Regulatory Affairs department with the occurrence reporting system and conducting Death Record Reviews in accordance with established procedures.  
• Serve as a resource to departmental management in reviewing proposed revisions to policies, procedures, and forms to determine regulatory compliance prior to implementation. 
• Serves as a Quality & Regulatory Affairs department resource in conducting Root Cause Analysis of reported occurrences, audit findings, etc. and providing reports of this analysis in accordance with established policy 
• Other duties as assigned. 
• Employees must adhere to and remain in full compliance with SFDN’s Motor Vehicle Driving Policy as outlined in the Motor Vehicle Records and Driver Safety policy PC.334. 

Reasonable Accommodations Statement  

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.  Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential functions. 

POSITION QUALIFICATIONS  

Competency Statement(s) – Position Specific 

• Accuracy - Ability to perform work accurately and thoroughly. 
• Active Listening - Ability to actively attend to, convey, and understand the comments and questions of others. 
• Conflict Resolution - Ability to deal with others in an antagonistic situation. 
• Customer Oriented - Ability to take care of the customers’ needs while following company procedures. 
• Detail Oriented - Ability to pay attention to the minute details of a project or task.  
• Honesty / Integrity - Ability to be truthful and be seen as credible in the workplace.  
• Organized - Possessing the trait of being organized or following a systematic method of performing a task.  
• Responsible - Ability to be held accountable or answerable for one’s conduct.  
• Self-Confident - The trait of being comfortable in making decisions for oneself.  
• Time Management - Ability to utilize the available time to organize and complete work within given deadlines.  

Competency Statement(s) - Company Specific 

• Understand and commit to the following:  
• Organizational Core Purpose: To save and heal lives.  
• Core Values: Relentless, Joyful, Selfless.  
• Strategic Anchors: Mutually beneficial partnerships, diverse revenue streams and get to yes: every donor every time 
• Team Builder - Ability to convince a group of people to work toward a goal.  
• Communication, Oral - Ability to communicate effectively with others using the spoken word.  
• Communication, Written - Ability to communicate in writing clearly and concisely.  
• Accountability - Ability to accept responsibility and account for his/her actions.  
• Judgment - The ability to formulate a sound decision using the available information. 
• Adaptability - Ability to adapt to change in the workplace. 
• Diversity Oriented - Ability to work effectively with people regardless of their age, gender, race, ethnicity, religion, or job type. 
• Compliance – Ability of the individual to be in accordance with established guidelines, policy, standards, or legislation. 

SKILLS & ABILITIES  

Education: Bachelor's degree in physical sciences or quality studies is required. Equivalent work experience may be substituted for education. 

Experience: Four to six years of auditing experience in regulated or certified industry.  

Experience working with an Organ Procurement Organization is preferred. 

Computer Skills: Proficient with Microsoft office suite. Knowledge of Q-pulse or other quality management software preferred. 

Certificates & Licenses: ASQ certification preferred; years of experience may be considered in lieu of certification. Certification must be obtained within 18 months of employment.  

Other Requirements: Knowledge of human anatomy and medical terminology is preferred.  

Experience with electronic medical records is preferred.