Overview

Under the supervision of the Director of Quality Management, will oversee and coordinate continuous regulatory efforts and quality management.

• Serves as a resource to hospital and medical staff departments to ensure the compliance with regulatory agency standards.
• Oversees and coordinates the collection, analysis, and data reporting related to ongoing regulatory compliance efforts.
• Responsible for supporting quality department scopes of work and providing leadership assistance and support for reaching established goals related to but not limited to performance improvement, OPPE/Peer Review, Quality Projects, Clinical Safety, and Value Based Quality Initiatives.

Responsibilities

1. Provides strategic leadership to support the hospital and department in meeting and exceeding their commitment to continuous regulatory compliance, clinical safety, quality projects and ongoing performance improvement
2. Manages performance, including other management positions through staffing, competency assessment, performance evaluation, and disciplinary action.
3. Ensures orientation and training for employees, including physicians and other leaders related to assigned scopes of work
4. Provides direct oversight of regulatory readiness staff activities
5. Manages departmental budget and productivity standards
6. Interviews, selects, hires, and retains employees, including other management positions
7. Promotes, demotes, or transfers employees to meet organizational needs, including other management positions
8. Executes progressive discipline up to and including termination
9. Oversees the design, implementation and reporting related to performance improvement activities
10. Performs long range planning and overall direction setting at the departmental level
11. Responsible for department organizational structure and alignment to meet forecasted business needs
12. Responsible for development, implementation and interpretation of system policies within a major organizational/functional area or the development and review of system policies within a recognized discipline
13. Approves payroll and is responsible for accurate payment of employees, including other management positions

DCH Standards:

• Maintains performance, patient and employee satisfaction and financial standards as outlined in the performance evaluation.
• Performs compliance requirements as outlined in the Employee Handbook
• Must adhere to the DCH Behavioral Standards including creating positive relationships with patients/families, coworkers, colleagues and with self.

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``` - Performs essential job functions in a manner that ensures the safety of patients, visitors and employees. - Identifies and reduces unsafe practices that may result in harm to patients, visitors and employees. - Recognizes and takes appropriate action to reduce risks and hazards to promote safety for patients, visitors and employees.

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``` - Requires use of electronic mail, time and attendance software, learning management software and intranet. - Must adhere to all DCH Health System policies and procedures. - All other duties as assigned.

Qualifications

Licensed Registered Nurse with current licensure in the state of Alabama

Bachelors degree in nursing, health administration, public health, or business administration required

Minimum of 5 years experience in an acute healthcare setting required

Proven current regulatory compliance and survey processes skills required

Management or supervisory experience/training in a health related field required

Quality Management experience required

Ability to establish priorities, meet deadlines, and maintain proper productivity

Ability to form positive, collaborative relationships with hospital staff, physicians, patients, regulatory compliance consultants

A ility to problem solve in a proactive, creative manner, using sound judgement based on factual information and clinical knowledge

Must have excellent leadership skills

Ability to lead and actively participate in multidisciplinary teams

Excellent computer skills-p