Clinical Compliance RN

Responsibilities

• Conduct comprehensive audits of medication administration records (MAR/eMAR/QMAR) to ensure medication accuracy and compliance.
• Review QMAR documentation daily to identify medication discrepancies, omissions, documentation errors, and compliance concerns.
• Perform medication chart audits and medication storage inspections.
• Audit nursing documentation for completeness, accuracy, timeliness, and regulatory compliance.
• Conduct routine clinical record reviews, including admissions, physician orders, treatment plans, medication records, and discharge documentation.
• Ensure all clinical documentation meets federal, state, payer, and accreditation requirements.
• Monitor organizational compliance with:
  • HIPAA
  • DHHS Regulations
  • CMS Standards
  • CARF Standards
  • Joint Commission Standards
  • North Carolina Behavioral Health Regulations
  • Other applicable state and federal regulations
• Remain current on regulatory changes and communicate updates to leadership.
• Participate in organizational Quality Improvement (QI) initiatives.
• Identify compliance trends and recurring deficiencies.
• Develop corrective action plans and monitor their implementation and effectiveness.
• Assist leadership with preparation for audits, licensing reviews, accreditation surveys, and inspections.
• Participate in internal mock surveys and compliance readiness activities.
• Provide intentional, observation-based clinical education to improve staff performance, including:
  • Conducting medication compliance training once each month at both the Wake County and Pitt County locations.
  • Training Paraprofessionals (PPs), Qualified Professionals (QPs), and clinical staff on medication administration standards, documentation requirements, infection control, and regulatory expectations.
  • Providing immediate coaching following observed deficiencies.
  • Developing individualized education based upon staff performance and identified trends.
• Serve as a clinical resource by proactively addressing staff questions and concerns before they become compliance issues.
• Investigate:
  • Medication errors
  • Medication omissions
  • Clinical incidents
  • Documentation deficiencies
  • Compliance violations
  • Reportable events
• Provide findings, recommendations, and corrective actions to leadership.
• Develop new compliance policies, review existing clinical policies, and update procedures based on regulatory changes and organizational needs.
• Recommend process improvements that strengthen compliance and improve patient outcomes.
• Collaborate with executive leadership to:
  • Correct identified deficiencies
  • Improve clinical processes
  • Strengthen regulatory readiness
  • Reduce organizational risk
  • Enhance quality of care
• Serve as the liaison between clinical staff, executive leadership, regulatory agencies, surveyors, and external healthcare partners.

Travel Requirements

• Travel between Wake County and Pitt County locations.
• Travel to the Pitt County location a minimum of twice per month.
• Conduct onsite medication cart audits and compliance reviews.
• Attend meetings as requested by executive leadership.
• Reliable transportation is required.