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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.

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