Job Summary

Summary

Responsible for overseeing and ensuring the quality and compliance of healthcare services within the organization. This position involves developing, implementing, and monitoring quality improvement programs, ensuring adherence to regulatory requirements, and leading initiatives to improve patient care, safety, and operational efficiency.

Does this position require Patient Care?

No

Essential Functions

-Execute quality and clinical compliance strategy within the organization, ensuring adherence to standardized processes around quality measurement, strategy, prioritized areas, and performance improvement while also providing critical feedback about issues and needs that are arising within.

-Track & execute necessary improvement for CMS conditions of participation, government, and private payer pay for performance activities in the quality and equity domains.

-Responsible for partnering with the data and analytics team as needed to ensure that reporting to CMS and other regulatory bodies is timely and correct.

-Execute and track any performance improvements as a result of safety events.

-Executes quality performance improvement plans and partners with local teams and department or floor-based teams to implement improvements as needed.

-Executes compliance activities, ensuring adherence to standardized processes around tracer activity, site-level preparedness activities, and measuring/monitoring compliance.

-Staff member for all compliance activities, ensuring the organization meets or exceeds all those measures.

-Supports local training and educational programs as needed.

-Understand data provided by the system team and use knowledge of local practices and culture to identify areas of opportunity for improvement as well as communicate to the system areas that are at risk.

Qualifications

Education

Bachelor's Degree Related Field of Study required

Can this role accept experience in lieu of a degree?

No

Licenses and Credentials

Experience

Experience in quality and clinical compliance within a hospital 3-5 years required and Clinical background experience 3-5 years preferred

Knowledge, Skills and Abilities

- Knowledge of principles of quality measurement, governmental and regulatory quality requirements, and process improvement.

- Demonstrated knowledge in executing improvements in clinical care, as well as holding themselves accountable to sustaining improvement over time.

- Demonstrated ability to execute a local quality performance and improvement portfolio.

- Other areas of knowledge include medical records systems; management information systems; applicable statutes and regulatory agency requirements, problem assessment and problem-solving techniques, health care law, health care services

- Excellent and effective verbal and written communication skills, as well as organization.

- Ability to interact with individuals and groups at any level; good decision-making skills; personnel management skills

- Excellent organizational skills, ability to work on multiple projects under multiple deadlines; highly energetic and able to embrace challenges and change.

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Responsibilities

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Qualifications

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