Regulatory Affairs Professionals Society
System Director of Quality and Accreditation Management
Regulatory Affairs Professionals Society, Juneau, Alaska, us, 99812
Job Description SummaryResponsible for the leadership, strategic direction, and management of the day-to-day activities of all Performance Improvement/Quality and Risk Management program, including accreditation, infection prevention and control, employee health screening, patient safety, risk management, compliance, credentialing, coordination of regulatory and accreditation compliance survey, and all other quality related activities.Key Essential Functions and Accountabilities of the JobDevelops and maintains the structure of the Quality and Accreditation Management division and fosters cross-disciplinary, cross-department, and cross-jurisdictional relationships.
Develops and manages the SEARHC Performance Improvement/Quality Management program; leads and integrates quality improvement beyond the clinical setting to all divisions.
Formulates, analyzes and implements Performance Improvement policies, programs and procedures in alignment with SEARHC objectives.
Manages SEARHC’s accreditation requirements to ensure compliance with accrediting body standards; provides guidance regarding credentialing issues; serves as subject matter expert for interpretation and application of accreditation standards.
Approves and ensures compliance by applying consistent quality improvement processes; understands and utilizes rapid PDSA (Plan-Do-Study-Act) cycles as part of the performance/quality improvement initiative; implements SEARHC Quality Management (SQM) concepts and perfect performance/quality improvement measures; promotes the SEARHC Seven Standards of Excellence.
Works with Electronic Health Record (EHR) staff to incorporate capacity for quality measure; trains staff, providers, etc. to input quality measurement data; develops quality measurement reports.
Provides technical and/or administrative support to staff, patients and others in resolving complaints and/or administrative problems; investigates complaints and concerns by collecting pertinent information; provides summary and recommendation action to the COO or directly respond to patients, staff, or others as appropriate; reports findings to Executive Leadership Team and/or SEARHC Board of Directors.
Other FunctionsOther duties as assigned.
Supervisory ResponsibilitiesThis position does require supervisory responsibilities.
Education, Certifications, and Licenses RequiredBSN or comparable clinical degree with other specialized education/training in two or more of the following: infection control or epidemiology, risk management, performance/quality improvement, and/or utilization management.
Master’s degree in health related or business field preferred
Certified Professional in Healthcare Quality (CPHQ) required within 18 months of hire
Experience RequiredFive years’ health care administration or performance improvement management experience
Three years’ experience supervising health care professionals
Knowledge ofQuality and performance improvement strategies and processes
Accrediting agency requirements, infection prevention, safety practices, risk management and total quality management principles
Alaska Native/American Indian health problems and the health service delivery program for Alaska Native/American Indians
Skills inProgram planning, implementation and evaluation
Critical thinking
Ability toLead, motivate and maintain a high performing team through effective performance management, communication and mentoring/coaching
Communicate with all levels of the organization professionally and comfortably present to internal and external audiences, physicians, media, and administration
Affect change through influence, working closely with all departments
Operate with a sense of urgency with rapid response capabilities, on constricted timelines and able to manage multiple projects at one time, with varying priority
Understand changing healthcare market dynamics, translating them into actionable strategy and implementing the strategy to achieve pre-set objectives
Apply broad knowledge and experiences when making sound decisions under conditions of uncertainty and time pressure.
Analyze and understand the financial and ethical implications of health program decisions
Travel RequiredTravel expected.
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Develops and manages the SEARHC Performance Improvement/Quality Management program; leads and integrates quality improvement beyond the clinical setting to all divisions.
Formulates, analyzes and implements Performance Improvement policies, programs and procedures in alignment with SEARHC objectives.
Manages SEARHC’s accreditation requirements to ensure compliance with accrediting body standards; provides guidance regarding credentialing issues; serves as subject matter expert for interpretation and application of accreditation standards.
Approves and ensures compliance by applying consistent quality improvement processes; understands and utilizes rapid PDSA (Plan-Do-Study-Act) cycles as part of the performance/quality improvement initiative; implements SEARHC Quality Management (SQM) concepts and perfect performance/quality improvement measures; promotes the SEARHC Seven Standards of Excellence.
Works with Electronic Health Record (EHR) staff to incorporate capacity for quality measure; trains staff, providers, etc. to input quality measurement data; develops quality measurement reports.
Provides technical and/or administrative support to staff, patients and others in resolving complaints and/or administrative problems; investigates complaints and concerns by collecting pertinent information; provides summary and recommendation action to the COO or directly respond to patients, staff, or others as appropriate; reports findings to Executive Leadership Team and/or SEARHC Board of Directors.
Other FunctionsOther duties as assigned.
Supervisory ResponsibilitiesThis position does require supervisory responsibilities.
Education, Certifications, and Licenses RequiredBSN or comparable clinical degree with other specialized education/training in two or more of the following: infection control or epidemiology, risk management, performance/quality improvement, and/or utilization management.
Master’s degree in health related or business field preferred
Certified Professional in Healthcare Quality (CPHQ) required within 18 months of hire
Experience RequiredFive years’ health care administration or performance improvement management experience
Three years’ experience supervising health care professionals
Knowledge ofQuality and performance improvement strategies and processes
Accrediting agency requirements, infection prevention, safety practices, risk management and total quality management principles
Alaska Native/American Indian health problems and the health service delivery program for Alaska Native/American Indians
Skills inProgram planning, implementation and evaluation
Critical thinking
Ability toLead, motivate and maintain a high performing team through effective performance management, communication and mentoring/coaching
Communicate with all levels of the organization professionally and comfortably present to internal and external audiences, physicians, media, and administration
Affect change through influence, working closely with all departments
Operate with a sense of urgency with rapid response capabilities, on constricted timelines and able to manage multiple projects at one time, with varying priority
Understand changing healthcare market dynamics, translating them into actionable strategy and implementing the strategy to achieve pre-set objectives
Apply broad knowledge and experiences when making sound decisions under conditions of uncertainty and time pressure.
Analyze and understand the financial and ethical implications of health program decisions
Travel RequiredTravel expected.
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