DIRECTOR, QUALITY/RISK MANAGEMENT - General John J. Pershing Memorial Hospital : Job Details

Job Summary:The Director of Quality Control/Risk Management will develop, implement, and periodically evaluate the system quality program to ensure the organization's compliance with state and federal regulations. Maintains the Risk Management program with attention to Patient Safety and patient grievances.Supervisory Responsibilities :

• none

Duties/Responsibilities:

• Accountable for management of the overall Quality and Performance Improvement program including reporting to the Board and Medical Staff.
• Oversees interdisciplinary performance improvement projects in consultation with staff, management and medical staff utilizing established quality methodologies.
• Assists department directors with development of ongoing quality monitors.
• Responsible for coordination and response to regulatory licensure surveys.
• Responsible for the Risk Management program activities including tracking and analyzing risk management data, working with liability insurance carrier on claims and participating with Patient Safety activities as needed.
• Periodically evaluates clinical departments with mock surveys for survey preparedness.
• Coordinates ongoing Medical Staff peer review as appropriate.
• Assists with maintenance and completion of HER Interoperability Program.
• Performs other related duties as assigned.
• Adheres to facility's Standards of Excellence.
• Reviews departmental policies and assists with the revision and development of new policies and procedures, to meet applicable law and regulations.
• This is a safety sensitive position.
• Handles discipline and termination of employees in accordance with company policy.

RequirementsRequired Skills/Abilities

• Excellent verbal and written communication skills with the ability to train staff.
• Thorough understanding of quality regulations and methodologies.
• Excellent organizational skills and attention to detail.
• Strong analytical and problem solving skills.
• Strong leadership skills.
• Proficient with Microsoft Office Suite or related software.

Education and Experience

• RN degree or clinical equivalent experience, BSN, BA, or Master's Degree preferred.
• Minimum 5 years in a clinical areas, prefer experience in quality or regulatory compliance.
• CPHQ certificate preferred.

Physical Requirements:

• Prolonged periods sitting at a desk and working on a computer
• Must be able to lift up to 15 pounds at times.