LinkedIn and 3rd parties use essential and non-essential cookies to provide, secure, analyze and improve our Services, and to show you relevant ads (including professional and job ads) on and off LinkedIn. Learn more in our Cookie Policy.
Select Accept to consent or Reject to decline non-essential cookies for this use. You can update your choices at any time in your settings.
Our hospitals provide high-quality care that transforms the lives of those living with disabling injuries and illnesses. We distinguish ourselves through our commitment to excellence, to our patients, to our employees, and to the communities we serve.
The Area Director of Quality provides clinical leadership for the following areas: Medical Staff Services, Regulatory Compliance, Risk Management, and Quality Management/Improvement. This position must integrate company values into daily practice.
Essential Functions
Facilitates compliance for the Hospital related to CMS, The Joint Commission, and State/Federal regulations. Completes audits to identify ongoing compliance.
Makes Hospital visits at least quarterly, or as needed, to assigned hospitals to perform onsite analysts of ongoing performance of quality program.
Prepares Medical Staff, hospital and hospital staff for survey activities by regulatory and accrediting agencies. Drafts survey responses to regulatory and accreditation agencies.
Collaborates with the medical staff regarding functions related to medical staff privileging and credentialing, performance improvement measurements, professional practice evaluation development and reviews, and aggregation by practitioners.
Facilitates the hospital performance improvement program through the collaboration with other hospital leaders. Provides guidance regarding measurements, data collection, analysis, conclusions, and process improvement.
Implements and manages clinical risk management functions including incident reporting, investigational follow up, grievances, root cause analysis, provides notices of potential claims, and litigation management in conjunction with senior leadership.
Educates Medical Staff and hospital employees during initial orientation, re-orientation, and as education in area of expertise is indicated.
Ensures submission of data to internal and external databases, as required by accreditation and regulatory agencies, is submitted timely and accurately.
Provides an environment conducive to safety for patients, visitors, and staff.
Assesses the risks for safety and implements appropriate precautions.
Shares patient satisfaction data with leadership/staff monthly and coordinates improvement. Identifies opportunities for improvement and coordinates the organizational efforts to improve patient satisfaction.
Performs other duties as assigned to support overall effectiveness of the organization.
Minimum Job Requirements
Minimum Education & Experience
Bachelor's Degree in a biological science required
Minimum four years clinical experience preferred
Two years in clinical compliance role preferred
Relevant education/experience may be substituted for one another in accordance with Hospital requirements