Job Summary:
In addition to the responsibilities listed above, this role is also responsible for: guiding others to schedule and perform the site reviews, medical record reviews, and Physical Accessibility Review (PAR) surveys; independently conducting complex site visits for ambulatory care and affiliated sites, as needed; independently creating, planning, and enacting strategy to ensure survey performance is in accordance with all regulatory requirements via rounds with staff, leaders, and providers; building educational complex principles for the relevant topic (e.g., stroke certifications) to aid staff understanding of organizational priorities; evaluating alignment of patient care towards standards and statues within the program as well as compliance with regulatory, accreditation programs, and national guidelines, independently; serving as a consultative resource for complex regulatory and accreditation programs recommendations, relevant program practice guidelines, order sets; conducting the planning and execution of long-term Ambulatory Surgery Centers/Units (ASCs or ASUs) quality and patient safety priorities, in alignment with regional and organization-wide goals; serving as an internal expert resource for aid in development and implementation of regional strategies that include a region-wide plan for routine surveillance of quality and patient safety systems and policy administration in the regions ASCs/ASUs; participating in regional cross-functional teams, as appropriate, to drive clinical improvements and efficient use of resources; driving others to support Graduate Medical Education (GME) for non-physician roles (Hospital Markets Only); independently communicating regulatory, policy, patient safety and quality program status and issues to program leads, business owners, and leadership; may be helping to define issues and provide consultative expertise for regulatory and accreditation programs recommendations, relevant program practice guidelines; and coordinating and maintaining clinical and service quality improvement activity summaries for regulatory oversight bodies.

Essential Responsibilities:

Promotes learning in others by communicating information and providing advice to drive projects forward; builds relationships with cross-functional stakeholders. Listens, responds to, seeks, and addresses performance feedback; provides actionable feedback to others, including upward feedback to leadership and mentors junior team members. Practices self-leadership; creates and executes plans to capitalize on strengths and improve opportunity areas; influences team members within assigned team or unit. Adapts to competing demands and new responsibilities; adapts to and learns from change, challenges, and feedback. Models team collaboration within and across teams.

Conducts or oversees business-specific projects by applying deep expertise in subject area; promotes adherence to all procedures and policies. Partners internally and externally to make effective business decisions; determines and carries out processes and methodologies; solves complex problems; escalates high-priority issues or risks, as appropriate; monitors progress and results. Develops work plans to meet business priorities and deadlines; coordinates and delegates resources to accomplish organizational goals. Recognizes and capitalizes on improvement opportunities; evaluates recommendations made; influences the completion of project tasks by others.

Serves as the subject matter expert for regulations projects/committees, and internal stakeholders by: providing consultation on the interpretation and interaction of current policies, and how they interact with the current climate, and potential changes to regulations and legislation; serving as a technical advisor on committees and projects to drive development of policies or procedures for regulations and auditing processes; developing complex content and delivering tailored educational programs to align organizational policies and procedures with regulatory requirements; and anticipating and weighing practical/technical considerations in addressing issues and coordinating with the appropriate stakeholders to develop resolutions.

Develops data management and reporting processes by: entering complex practitioner/provider data and conducts data cleaning as needed; and entering, analyzing, and independently drafting and reviewing action plans/recommendations required data into appropriate databases.

Ensures licensing and accreditation by: independently reviewing and guiding others to review requirements for new, existing, and expanding facilities/services to aid in achievement of compliance with state, federal, and accrediting standards; consulting with other departments to ensure certification for complex cases; and independently conducting a widely impactful and detailed gap analysis and mentoring others to identify services renewals and planning to ensure services are compliant.

Identifies and recommends improvements to processes of responding to regulatory audits and survey preparedness efforts by: independently enacting complex reporting, keeping current on regulatory requirements, and guiding others to do the same in preparation for surveys (e.g., NCQA, Joint Commission, AAAHC); serving as liaison between external evaluators, vendors, and senior stakeholders to facilitate on-site visits and evaluations; independently conducting, reviewing, evaluating upon site visit criteria, and performing site visits as appropriate to ensure survey readiness; delivering requested complex audit documentation, information, and reports; assessing the workflow of auditing surveys to identify gaps in completion and reporting, focusing on high vulnerability areas; facilitating educational forums, conducting routine audits, and leading mock surveys within departments to ensure auditing and survey preparedness tracking, trending, and facilitating the development of high impact corrective action plans (CAP) as necessary in collaboration with applicable departments to assure site visit compliance; and leading the collaborations with other departments (e.g., Revenue Cycle), gathering documents and data to support the timely completion of the annual state/federal/regulatory body reporting as required.

Minimum Qualifications:

Minimum three (3) years of experience in a leadership role with or without direct reports.

Minimum three (3) years of experience with databases and spreadsheets.

Bachelors degree in Business Administration, Health Care Administration, Nursing, Public Health, or related field AND minimum seven (7) years of experience in health care operations, quality, risk management, hospital environment, or a directly related field OR minimum ten (10) years of experience in health care operations, quality, risk management, hospital environment, or a directly related field.

Additional Requirements:

Knowledge, Skills, and Abilities (KSAs): Health Care Policy; Health Care Data Analytics; Consulting; Managing Diverse Relationships; Delegation; Project Management; Risk Assessment; Quality Assurance Process; Credentialing Database Systems; Health Care Quality Standards; Evidence-Based Medicine Principles