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.
Essential Functions
1. 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.
2. Track & execute necessary improvements for CMS conditions of participation, government, and private payer pay-for-performance activities in the quality and equity domains.
3. Partner with the data and analytics team to ensure timely and accurate reporting to CMS and other regulatory bodies.
4. Implement and monitor performance improvements resulting from safety events.
5. Develop and execute quality performance improvement plans, collaborating with local and departmental teams to implement necessary improvements.
6. Ensure compliance with tracer activities, site-level preparedness, and monitoring activities.
7. Participate in all compliance activities, ensuring the organization meets or exceeds required standards.
8. Support local training and educational programs as needed.
9. Utilize data from the system team alongside knowledge of local practices to identify improvement opportunities and communicate risks.
Education
Bachelor's Degree in a Related Field of Study is required. Experience in lieu of a degree is not accepted.
Licenses and Credentials
Not specified.
Experience
3-5 years of experience in quality and clinical compliance within a hospital setting is required. Clinical background experience of 3-5 years is preferred.
Knowledge, Skills, and Abilities
* Knowledge of quality measurement principles, governmental and regulatory requirements, and process improvement.
* Proven ability to implement and sustain clinical care improvements.
* Experience managing a local quality improvement portfolio.
* Familiarity with medical records systems, management information systems, and healthcare regulations.
* Excellent communication, organizational, and decision-making skills.
* Ability to interact effectively at all levels and manage multiple projects.
Physical Requirements
* Standing Occasionally (3-33%)
* Walking Occasionally (3-33%)
* Sitting Constantly (67-100%)
* Lifting Occasionally (3-33%)
* Carrying Occasionally (3-33%)
* Pushing Rarely (Less than 2%)
* Pulling Rarely (Less than 2%)
* Climbing Rarely (Less than 2%)
* Balancing Occasionally (3-33%)
* Stooping Occasionally (3-33%)
* Kneeling Rarely (Less than 2%)
* Crouching Rarely (Less than 2%)
* Crawling Rarely (Less than 2%)
* Reaching Occasionally (3-33%)
* Gross Manipulation (Handling) Constantly (67-100%)
* Fine Manipulation (Fingering) Frequently (34-66%)
* Feeling Constantly (67-100%)
* Foot Use Rarely (Less than 2%)
* Vision - Far Constantly (67-100%)
* Vision - Near Constantly (67-100%)
* Talking Constantly (67-100%)
* Hearing Constantly (67-100%)
The Spaulding Rehabilitation Hospital Corporation is an Equal Opportunity Employer. We embrace diverse skills, perspectives, and ideas. All qualified applicants will receive consideration without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, or other protected status. Reasonable accommodations are provided for individuals with disabilities during the application, interview, and employment process.
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