Supervises and monitors one or more of the following activities, continuing medical education, quality assurance, medical staff services and quality projects.
Essential Functions:
- Supervises the daily quality activities, ensuring timely and accurate data collection, follow up of issues and quality of work. Coaches staff and ensures their competency.
- Coordinates and facilitates staff support to various committees (e.g., quality, accreditation) which includes agenda preparation and monitoring of outstanding issues.
- Provides reports based on timely and accurate data collection, identifies trends and monitors issues.
- Develops, implements, and monitors quality departments policies and procedures; ensures they are in compliance with The Joint Commission, NCQA, CME, federal, state and local requirements.
- Assists in developing and revising QA monitors to meet accreditation/regulatory standards.
- Monitors the budgets, researches variances, and identifies opportunities to reduce costs.
- Develops, implements, coordinates, and evaluates the CME programs, credentialing and privileges for permanent or temporary physicians and allied health providers.
- Assists in preparation of educational materials and course objectives.
- Maintains link between medical staff affairs and quality improvement, risk management, continuing medical staff education.
- Coordinates and prepares for CME, accreditation, licensing, and quality surveys/audits.
- Maintains and monitors the various quality databases which may include quality reviews, CME, credentials and privileges and provider profiles.
Qualifications:
Basic Qualifications:
- Significant (typically two (2) - three (3) years) of quality improvement or accreditation experience required.
- Knowledge and experience in application of adult learning theory in program development.
- Bachelor's degree or equivalent experience in a health care related field or business administration.
- Ability to perform statistical analysis.
- Current knowledge of The Joint Comission, NCQA, federal, state, and local requirements.
- Must be able to work in a Labor/Management Partnership environment.
Preferred Qualifications:
- Previous supervisory experience recommended.
- Experience with inpatient psychiatry quality and regulatory guidelines preferred.
- Experience with performance improvement methodology in health care preferred.
- Familiarity with application of lean six sigma methods preferred.
External hires must pass a background check/drug screen.
We are proud to be an equal opportunity/affirmative action employer.