Clinical Compliance RN

Essential Duties and Responsibilities

Clinical Compliance

• 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.

Regulatory Compliance

• 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.

Quality Assurance & Performance Improvement

• Participate in organizational Quality Improvement (QI) initiatives.
• Identify compliance trends and recurring deficiencies.
• Develop corrective action plans.
• Monitor implementation and effectiveness of corrective actions.
• Assist leadership with preparation for audits, licensing reviews, accreditation surveys, and inspections.
• Participate in internal mock surveys and compliance readiness activities.

Staff Training & Development

Provide intentional, observation-based clinical education to improve staff performance.

Responsibilities include:

• Conduct medication compliance training once each month at both the Wake County and Pitt County locations.
• Train Paraprofessionals (PPs), Qualified Professionals (QPs), and clinical staff on medication administration standards, documentation requirements, infection control, and regulatory expectations.
• Provide immediate coaching following observed deficiencies.
• Develop 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.

Incident Investigation

• Medication errors
• Medication omissions
• Clinical incidents
• Documentation deficiencies
• Compliance violations
• Reportable events

Provide findings, recommendations, and corrective actions to leadership.

Policy & Procedure Development

• Develop new compliance policies.
• Review existing clinical policies.
• Update procedures based on regulatory changes and organizational needs.
• Recommend process improvements that strengthen compliance and improve patient outcomes.

Leadership Collaboration

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
• External healthcare partners

Travel Requirements

Travel is required.

The Clinical Compliance RN must:

• Travel between Wake County and Pitt County.
• 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.