Cook County Health & Hospitals System
Director of Quality, Regulatory Affairs and Accreditation
Cook County Health & Hospitals System, Chicago, Illinois, United States, 60290
Director of Quality, Regulatory Affairs and AccreditationJob Number:
00134192
Job Posting
:
May 9, 2024, 3:32:59 PM
Closing Date
:
OngoingFull-time
Shift Start Time
:
8:30 A.M.
Shift End Time
:
4:30 P.M.
Collective Bargaining Unit
:
NONEPosting Salary
:
COMPETITIVE
Organization
:
Health and Hospital Systems
Applicants may apply for this position by submitting a resume/ CV to the following email address:
mgmtrecruit@cookcountyhhs.org
When submitting a resume/CV by email, you
must include the job title and posting number in the subject line of your email . An application or resume/CV must be filed for each position which interests you.
To receive Veteran Preference, appropriate discharge papers must be attached to the online application or must be included with your emailed resume/CV. Please refer to Veteran Preference document requirements listed on the bottom of this posting.
Job Summary
Under the direction of the Chief Quality Officer, directs the strategic management and planning for Joint Commission Accreditation and accreditation related activities for all clinical services throughout the health system, including hospitals, clinics, behavioral health centers and ambulatory surgery centers. Sets guidelines to meet requirements for Joint Commission Accreditation leading to successful accreditation for all entities within the health system. Develops and maintains a comprehensive accreditation project plan adhering to standards, prioritized interventions and on-going monitoring for compliance as established by Joint Commission for all accreditation requirements. Develops and manages a plan to assure compliance with Centers for Medicare and Medicaid Services (CMS) Conditions of Participation. Coordinates efforts to earn outstanding clinical performance and a positive customer experience as required for accreditation. Coordinates efforts to assure regulatory compliance with standards established by our managed care partners.
General Administrative Responsibilities
Collective Bargaining
Review applicable Collective Bargaining Agreements and consult with Labor Relations to generate management proposals
Participate in collective bargaining negotiations, caucus discussions and working meetings
Discipline
Document, recommend and effectuate discipline at all levels
Work closely with labor relations and/or labor counsel to effectuate and enforce applicable Collective Bargaining Agreements
Initiate, authorize and complete disciplinary action pursuant to CCH system rules, policies, procedures and provision of applicable collective bargaining agreements
Supervision
Direct and effectuate CCH management policies and practices
Access and proficiently navigate CCH records system to obtain and review information necessary to execute provisions of applicable collective bargaining agreements
Management
Contribute to the management of CCH staff and CCH’ systemic development and success
Discuss and develop CCH system policy and procedure
Typical Duties
Establishes guidelines to meet Joint Commission accreditation requirements
Develops and leads a regulatory survey readiness program in support of the organization's mission, values and business objectives
Develops and maintains a comprehensive project plan linked to standards with on-going monitoring and reporting to senior management
Serves as the System's resource in questions related to accreditation and to CMS standards
Works with CCHHS senior management and clinical staff in leading and managing all aspects of the accreditation process and standard adherence
Coordinates activities with subject matter experts and unit business owners
Conducts training and coaching to support understanding of accreditation standards and requirements
Develops and maintains plans to assure compliance with regulatory requirements of managed care plans
Develops and manages audit activities to ensure compliance with accreditation standards and develops and maintains a dashboard to demonstrate ongoing compliance
Facilitates communication of information among governance committees and serves as liaison on accreditation issues and changing standards
Maintains accreditation and audit document library
Maintains and updates policy library
Performs other duties as they might be assigned
Reporting Relationship
Reports to the Chief Quality Officer
ENTER TEXT HERE
Minimum Qualifications
Bachelor's degree from a four-year accredited university
Successful completion of the accreditation process resulting in a fully accredited designation
Five (5) years of experience in management or leadership role within a large hospital or healthcare system
Seven (7) years of experience with accreditation and regulatory survey process, development and follow-up of corrective plans
Proficiency using Microsoft Office (Outlook, Excel, Word, and PowerPoint)
Preferred Qualifications
Five (5) years of experience in developing and implementing an accreditation plan in healthcare environment
Master's or similar degrees in healthcare administration, such as MBA, MHA, MS, MPH, or MPA
Additional certification in healthcare quality management from a recognized organization
Expert knowledge of regulatory environment including Joint Commission, CMS, National Committee for Quality Assurance (NCQA)
Knowledge, Skills, Abilities and Other Characteristics
Excellent verbal and written communication skills necessary to communicate with all levels of staff and a patient population composed of diverse cultures and age groups
Excellent program development, management and leadership skills
Strong customer service and empathy skills
Must be able to work flexible hours
Must be able to travel throughout Cook County
Performs other duties as assigned
Physical and Environmental Demands
This position is functioning within a healthcare environment. The incumbent is responsible for adherence to all hospital and department specific safety requirements.
The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of the personnel so classified.
For purposes of the American with Disabilities Act, “Typical Duties” are essential job functions.
VETERAN PREFERENCE
PLEASE READ
When applying for employment with Cook County Health, preference is given to honorably discharged Veterans who have served in the Armed Forces of the United States for not less than 6 months of continuous service
To take advantage of this preference a Veteran
must :
Meet the minimum qualifications for the position.
Identify self as a Veteran on the employment application.
Attach a copy of their
DD 214, DD 215 or NGB 22
(Notice of Separation at time of application filing.
OR
A copy of a
valid State ID Card or Driver’s License
which identifies the holder of the ID as a Veteran, may also be attached to the application at time of filing.
If items are not attached, you will not be eligible for Veteran Preference
VETERANS MUST PROVIDE ORIGINAL APPLICABLE DISCHARGE PAPERS OR APPLICABLE STATE ID CARD OR DRIVER’S LICENSE AT TIME OF INTERVIEW.
MUST MEET ALL REQUIRED QUALIFICATIONS AT TIME OF APPLICATION FILING.
“Degrees awarded outside of the United States must be credentialed by an approved U.S. credential evaluation service belonging to the National Association of Credential Evaluation Services (NACES) or the Association of International Credential Evaluators (AICE). Original credentialing documents must be presented at time of interview”.
Please note all offers of Employment are contingent upon the following conditions: satisfactory professional & employment references, healthcare and criminal background checks, appropriate licensure/certifications and the successful completion of a physical and pre-employment drug screen.
*CCH is
strictly
prohibited
from
conditioning,
basing
or
knowingly
prejudicing
or affecting any term or aspect of
County
employment
or
hiring
upon
or
because
of any
political
reason
or
factor.
COOK COUNTY HEALTH IS AN EQUAL OPPORTUNITY EMPLOYER.
#J-18808-Ljbffr
00134192
Job Posting
:
May 9, 2024, 3:32:59 PM
Closing Date
:
OngoingFull-time
Shift Start Time
:
8:30 A.M.
Shift End Time
:
4:30 P.M.
Collective Bargaining Unit
:
NONEPosting Salary
:
COMPETITIVE
Organization
:
Health and Hospital Systems
Applicants may apply for this position by submitting a resume/ CV to the following email address:
mgmtrecruit@cookcountyhhs.org
When submitting a resume/CV by email, you
must include the job title and posting number in the subject line of your email . An application or resume/CV must be filed for each position which interests you.
To receive Veteran Preference, appropriate discharge papers must be attached to the online application or must be included with your emailed resume/CV. Please refer to Veteran Preference document requirements listed on the bottom of this posting.
Job Summary
Under the direction of the Chief Quality Officer, directs the strategic management and planning for Joint Commission Accreditation and accreditation related activities for all clinical services throughout the health system, including hospitals, clinics, behavioral health centers and ambulatory surgery centers. Sets guidelines to meet requirements for Joint Commission Accreditation leading to successful accreditation for all entities within the health system. Develops and maintains a comprehensive accreditation project plan adhering to standards, prioritized interventions and on-going monitoring for compliance as established by Joint Commission for all accreditation requirements. Develops and manages a plan to assure compliance with Centers for Medicare and Medicaid Services (CMS) Conditions of Participation. Coordinates efforts to earn outstanding clinical performance and a positive customer experience as required for accreditation. Coordinates efforts to assure regulatory compliance with standards established by our managed care partners.
General Administrative Responsibilities
Collective Bargaining
Review applicable Collective Bargaining Agreements and consult with Labor Relations to generate management proposals
Participate in collective bargaining negotiations, caucus discussions and working meetings
Discipline
Document, recommend and effectuate discipline at all levels
Work closely with labor relations and/or labor counsel to effectuate and enforce applicable Collective Bargaining Agreements
Initiate, authorize and complete disciplinary action pursuant to CCH system rules, policies, procedures and provision of applicable collective bargaining agreements
Supervision
Direct and effectuate CCH management policies and practices
Access and proficiently navigate CCH records system to obtain and review information necessary to execute provisions of applicable collective bargaining agreements
Management
Contribute to the management of CCH staff and CCH’ systemic development and success
Discuss and develop CCH system policy and procedure
Typical Duties
Establishes guidelines to meet Joint Commission accreditation requirements
Develops and leads a regulatory survey readiness program in support of the organization's mission, values and business objectives
Develops and maintains a comprehensive project plan linked to standards with on-going monitoring and reporting to senior management
Serves as the System's resource in questions related to accreditation and to CMS standards
Works with CCHHS senior management and clinical staff in leading and managing all aspects of the accreditation process and standard adherence
Coordinates activities with subject matter experts and unit business owners
Conducts training and coaching to support understanding of accreditation standards and requirements
Develops and maintains plans to assure compliance with regulatory requirements of managed care plans
Develops and manages audit activities to ensure compliance with accreditation standards and develops and maintains a dashboard to demonstrate ongoing compliance
Facilitates communication of information among governance committees and serves as liaison on accreditation issues and changing standards
Maintains accreditation and audit document library
Maintains and updates policy library
Performs other duties as they might be assigned
Reporting Relationship
Reports to the Chief Quality Officer
ENTER TEXT HERE
Minimum Qualifications
Bachelor's degree from a four-year accredited university
Successful completion of the accreditation process resulting in a fully accredited designation
Five (5) years of experience in management or leadership role within a large hospital or healthcare system
Seven (7) years of experience with accreditation and regulatory survey process, development and follow-up of corrective plans
Proficiency using Microsoft Office (Outlook, Excel, Word, and PowerPoint)
Preferred Qualifications
Five (5) years of experience in developing and implementing an accreditation plan in healthcare environment
Master's or similar degrees in healthcare administration, such as MBA, MHA, MS, MPH, or MPA
Additional certification in healthcare quality management from a recognized organization
Expert knowledge of regulatory environment including Joint Commission, CMS, National Committee for Quality Assurance (NCQA)
Knowledge, Skills, Abilities and Other Characteristics
Excellent verbal and written communication skills necessary to communicate with all levels of staff and a patient population composed of diverse cultures and age groups
Excellent program development, management and leadership skills
Strong customer service and empathy skills
Must be able to work flexible hours
Must be able to travel throughout Cook County
Performs other duties as assigned
Physical and Environmental Demands
This position is functioning within a healthcare environment. The incumbent is responsible for adherence to all hospital and department specific safety requirements.
The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of the personnel so classified.
For purposes of the American with Disabilities Act, “Typical Duties” are essential job functions.
VETERAN PREFERENCE
PLEASE READ
When applying for employment with Cook County Health, preference is given to honorably discharged Veterans who have served in the Armed Forces of the United States for not less than 6 months of continuous service
To take advantage of this preference a Veteran
must :
Meet the minimum qualifications for the position.
Identify self as a Veteran on the employment application.
Attach a copy of their
DD 214, DD 215 or NGB 22
(Notice of Separation at time of application filing.
OR
A copy of a
valid State ID Card or Driver’s License
which identifies the holder of the ID as a Veteran, may also be attached to the application at time of filing.
If items are not attached, you will not be eligible for Veteran Preference
VETERANS MUST PROVIDE ORIGINAL APPLICABLE DISCHARGE PAPERS OR APPLICABLE STATE ID CARD OR DRIVER’S LICENSE AT TIME OF INTERVIEW.
MUST MEET ALL REQUIRED QUALIFICATIONS AT TIME OF APPLICATION FILING.
“Degrees awarded outside of the United States must be credentialed by an approved U.S. credential evaluation service belonging to the National Association of Credential Evaluation Services (NACES) or the Association of International Credential Evaluators (AICE). Original credentialing documents must be presented at time of interview”.
Please note all offers of Employment are contingent upon the following conditions: satisfactory professional & employment references, healthcare and criminal background checks, appropriate licensure/certifications and the successful completion of a physical and pre-employment drug screen.
*CCH is
strictly
prohibited
from
conditioning,
basing
or
knowingly
prejudicing
or affecting any term or aspect of
County
employment
or
hiring
upon
or
because
of any
political
reason
or
factor.
COOK COUNTY HEALTH IS AN EQUAL OPPORTUNITY EMPLOYER.
#J-18808-Ljbffr