This position directs the Medical Center's operations & activities to comply w/ all accreditation, regulation, & licensing requirements for all health care sites & services across the continuum including, but not limited to: home health, ambulatory services, provider networks, hospital services & health plan. Translates various accrediting, regulatory & licensing agency requirements into action plans to achieve positive survey/audit reviews & renewed licenses and implements systems to effectively monitor compliance to standards & to implement new processes to meet new requirements.
Essential Functions:
- Directs the Medical Center's operations & activities to comply w/ all licensing & accreditation standards & requirements, ensuring consistency w/ organizational goals & priorities
- Works closely w/ designated Chiefs of Service & Department Managers to ensure and adhere to the principles of confidentiality & responsibility
- Determines strategy for changing existing processes to meet regulatory requirements & translating external demands into program goals
- Provides education & technical support to the Medical Center in developing, implementing & maintaining regulatory compliance
- Partners w/ Risk Management to reduce medical/legal liability through development of a program that links risk management activities w/ those of regulatory compliance
- Serves as a critical link in the identification & resolution of issues, which affect organizational image
- Develops & maintains relationships & effective communication w/ all levels of medical center physicians & staff in order to facilitate problem identification & resolution
- Manages staff & makes recommendations regarding the need for staff, space & other resources
- Manages & resolves human resources & labor relations issues specific to management responsibilities
- Develops systems, templates, tools & processes to identify & monitor indicators which best measure improvement in care delivery
- Analyzes, interprets & makes recommendations to meet federal, state & local requirements
- Identifies key accreditation, regulation & licensing issues & defines areas for improvement
- Establishes mechanisms for proactive identification of regulatory issues & tracking of corrective action to minimize negative impact & maximize learning
- Relays internal/external communication of information related to accreditation, regulation & licensing
- Partners w/ the Quality Director to prepare for surveys & inspections, including educational forums, coordinating mock surveys & assessments assists in developing response plans
- Coordinates formal surveys for all regulatory & accrediting agencies
- Interprets & assists in planning responses to new or changing regulations or standards.
- Collaborates w/ external regulators to develop standards that promote high quality patient care & services
- Serves as liaison to region, community groups, professional organizations, & licensing/regulatory agencies
- Develops, implements, & meets the established financial goals
- Monitors applicable budget; & identifies & supports solutions to reduce cost structure
Qualifications:
Basic Qualifications:
- Experience designing, developing, and implementing clinical improvement programs
- Significant experience (usually five (5) years) in Quality Improvement in a health care setting
- Previous management experience required
- Previous management experience in nursing or other allied health professional experience preferred
- Bachelor's degree in health care administration, nursing, or public administration or related field required
- Clinical licensure or master's degree in health care administration, nursing, or public administration or related field preferred
- Total Quality Management certification or Certified Professional of Healthcare Quality (CPHQ) preferred
- Demonstrated knowledge of governmental & other regulatory standards, requirements, & guidelines related to quality improvement, such as The Joint Commission, NCQA, Knox-Keene Act, Federal HMO Act, CMS Conditions of Participation, Title 22, Cal-OSHA, HIPAA & Medical & Medicare regulations & standards
- Strong working knowledge of ongoing monitoring techniques (including criteria development & statistical analysis); medical care delivery in hospital & outpatient settings; total quality management principles, tools, & techniques
- Effective communication, negotiation, & leadership skills
External hires must pass a background check/drug screen.
We are proud to be an equal opportunity/affirmative action employer.