Director of Accreditation and Regulatory- Full Time Days

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Summary

MAJOR JOB FUNCTIONS:

The following is a summary of the major essential functions of the job.  The incumbent may perform other duties, both major and minor, that are not mentioned below; and specific functions may change from time to time.

• Leads Corporate Leapfrog initiatives and ensures that all facilities are tracking these measures for success

• Leads the organization in Readmission Reduction Program in collaboration with leadership

• Participates in processes that assure local, regional/market and corporate standards that dictate care, patient safety and clinical practices as outlined in policies, procedures, forms, and other documents.

• Participates inCorporate, Disease Specific Certifications.

• Implement and assist with projects related to clinical quality improvement (QI), quality measurement and QI research in the Division of Quality and Patient Safety.

• Works with the Quality team to develop activities related to VBP, HAC, HRRP, Care Compare data to decrease financial implications.

• Works with all levels of leadership and front-line staff to facilitate and support the development and integration of evidence-based best practices at the department/program level.

• Review of corporate policies and procedures to ensure regulatory compliance.

• Assessment of corporate compliance and submission of Leapfrog survey

• Actively participates in regulatory surveys to provide relevant data as necessary and maintains constant preparation.

• Data collection, database development and basic statistical analyses from information gathered in patient surveys, electronic health records, hospital administrative databases, and other sources.

• Other duties as assigned

MINIMUM QUALIFICATIONS:

The following qualifications, or equivalents, are the minimum requirements necessary to perform the essential functions of this job:

EDUCATION AND FORMAL TRAINING:

• Bachelor’s degree in nursing, computer science or other healthcare related field required

• Certification (CPHQ), American Society for Quality (ASQ) or other related quality certification preferred

WORK EXPERIENCE:

• 3 years of healthcare related experience required.

• Experience in working with The Joint Commission and CMS standards preferred. Working knowledge of EPIC, Press Ganey, BI, Premier, Microsoft Office, and SPSS preferred.

KNOWLEDGE, SKILLS, AND ABILITIES REQUIRED:

• Proficiency in reading, writing and speaking the English language

• Knowledge of theories, principles, and methods utilized in the development of health quality databases and analysis of health quality data preferred.

• Knowledge of survey, accreditation and regulatory processes required.

• Must be independent, efficient and have exceptional interpersonal skills, as interaction with patients, families, and medical staff is necessary.

PHYSICAL REQUIREMENTS:

• Must be able to move throughout the Health System without difficulty, stand and sit for long periods of time.

Required Licenses and Certifications

Cape Fear Valley Health System is an Equal Opportunity EmployerM/F/Disability/Veteran/Sexual Orientation/Gender Identity