Direct the Medical Center(s), Residential Treatment and Ambulatory Surgery Center(s) operations and activities to comply with all accreditation, regulation, and licensing requirements. Provide oversight for building safety programs to ensure compliance with regulatory and accreditation standards. Translates various accrediting, regulatory and licensing agency requirements into action plans to achieve positive survey/audit reviews and renewed licenses. Implements systems to effectively monitor compliance to standards and to implement new processes to meet new requirements.
Essential Functions:
- Manages operations and activities to comply with all licensing and accreditation standards and requirements, ensuring consistency with organizational goals and priorities:
- Works closely with designated Chiefs of Service and Department Managers to ensure that principles of confidentiality and responsibility are adhered to.
- Partners with Compliance and Risk Management to reduce medical/legal liability through development of a program which links risk management activities with those of regulatory compliance.
- Partners with the Quality Director to prepare for surveys and inspections, including educational forums, coordinating mock surveys and assessments assists in developing response plans.
- Determines strategy for changing existing processes to meet regulatory requirements and translating external demands into program goals.
- Provides education and technical support to the Medical Centers, Residential Treatment and Ambulatory Surgery Centers in developing, implementing and maintaining regulatory compliance.
- Serves as a critical link in the identification and resolution of issues, which affect organizational image.
- Develops and maintains relationships and effective communication with all levels of medical center physicians and staff in order to facilitate problem identification and resolution.
- Ensures continuous readiness and monitors compliance for designated facilities:
- Develops systems, templates, tools and processes to identify and monitor indicators which best measure improvement in care delivery.
- Coordinates formal surveys for all regulatory and accrediting agencies.
- Translates regulatory/agency requirements into action plans that achieve positive outcomes:
- Analyzes, interprets and makes recommendations to meet federal, state and local requirements.
- Identifies key accreditation, regulation and licensing issues and defines areas for improvement.
- Establishes mechanisms for proactive identification of regulatory issues and tracking of corrective action to minimize negative impact and maximize learning.
- Relays internal/external communication of information related to accreditation, regulation and licensing and serves as liaison to region, community groups, professional organizations, and licensing/regulatory agencies.
- Interprets and assists in planning responses to new or changing regulations or standards.
- Collaborates with external regulators to develop standards that promote high quality patient care and services.
- Manages staff and makes recommendations regarding the need for staff, space and other resources.
- Manages and resolves human resources and labor relations issues specific to management responsibilities.
Qualifications:
Basic Qualifications:
- Seven (7) years in Quality Improvement in a health care setting including designing, developing, and implementing programs.
- Five (5) years of management experience.
- Bachelor's degree in health care administration, nursing, or public administration or related field required.
- CPHQ certification within 12 months of hire.
- Demonstrated knowledge of governmental and other regulatory standards, requirements, and guidelines related to quality improvement, such as TJC, NCQA,Federal HMO Act, CMS Conditions of Participation, HIPAA and Medicare regulations and standards.
- Strong working knowledge of ongoing monitoring techniques (including criteria development and statistical analysis); medical care delivery in hospital and outpatient settings; total quality management principles, tools, and techniques.
- Effective communication, negotiation and leadership skills.
- Must be able to work in a Labor/Management Partnership environment.
Preferred Qualifications:
- Previous management experience in nursing or other allied health professional experience preferred.
- Master's degree in health care administration, nursing, public administration or a related field preferred.
- Clinical licensure preferred.
- Total Quality Management certification or Certified Professional of Healthcare Quality (CPHQ) preferred.
External hires must pass a background check/drug screen.
We are proud to be an equal opportunity/affirmative action employer.