Job Description

The POLICY AND PROCEDURE COORDINATOR reflects the mission, vision, and values of NM, adheres to the organization’s Code of Ethics and Corporate Compliance Program, and complies with all relevant policies, procedures, guidelines and all other regulatory and accreditation standards.

Manages committees, communication among managers and executives, policy and procedure data base and software programs to ensure timely and accurate review, update and posting of policies and procedures. Provides administrative support to the Policy Committee. Requires excellent organization and verbal/written communication skills, including the ability to interact effectively in group and one-on-one situations at all levels of the organization.

RESPONSIBILITIES:

• Manages policy and procedure database, establishing and enforcing standards for structure, content and format.
• Coordinates maintenance of administrative policies on policy management software.
• Coordinates enterprise-wide maintenance of administrative and departmental procedures on the database.
• Develops educational resources and training for staff who write, review, edit and use policies, procedures, clinical guidelines and clinical protocols.
• Develops educational resources and training for staff who are responsible for local departmental policies, including organization, retention, format, and support to assure aligned and professional local resources.
• Trains authorized users of the system, reviews and approves content.
• Monitors revisions, additions of enterprise-wide procedures to ensure consistency across departments.
• Assists with editing and formatting relevant documents.
• Participates in policy committee activities.
• Provides coordination and leadership in aligning policies across NMHC organizations.
• Provides guidance to assist policy owners to meet relevant regulatory and accreditation standards related to policies/procedures.
• Supports administrative activities (inventory, review cycles, updates) related to other domains such as forms and physician order sets.

Qualifications

REQUIRED:

• Bachelor’s degree in relevant field 
• Minimum 3 years of experience with clinical vocabulary and acute care processes, policies, and procedures 
• Experience in project management
• Excellent interpersonal skills.
• Working knowledge of the following applications: MS Office. Proficient with MS Word
• Knowledge of Internet and Intranet resources. 
• Good proofreading skills
• Outstanding and meticulous organizational skills

PREFERRED:

• Hospital experience of 5-7 years in a clinical or administrative role with specific experience in dealing with policies, procedures, or accreditation and regulatory agencies. 
• Working knowledge of TJC standards and CMS Conditions of Participation.

Additional Information

Northwestern Medicine is an affirmative action/equal opportunity employer and does not discriminate in hiring or employment on the basis of age, sex, race, color, religion, national origin, gender identity, veteran status, disability, sexual orientation or any other protected status.