Manager, Quality And Special Projects

• Bachelor's Degree

• REQUIRED

• Bachelor's / Master's Degree in Nursing, Masters in Public Health, Master's Degree in Business Administration, Masters of Science, Masters of Art

• PREFERRED

• Three (3) to five (5) years of experience in healthcare management or healthcare education.

• Prior healthcare industry experience, especially in the areas of quality or regulatory management, project management and/or change management

• PREFERRED· Experience in HIV primary care setting

• CPHQ / Lean Six Sigma Certified

• PREFERRED

• Strong knowledge of data reporting procedures by the Joint Commission, IPRO, Department of Health and National Data Nursing Quality Improvement (NDNQI).

• Development, implementation, and evaluation of the nursing department's overall quality improvement (QI) and regulatory program.

• Identification, monitoring and evaluating trends, prioritizing and recommending improvements, decrease duplication, and ensures compliance with The Joint Commission (TJC) requirements.

• Investigate incident reports, patient complaints, patient care issues, and other issues as requested by the Nursing Leadership team.

• Supports nursing and its leaders and staff to ensure full compliance with state licensure regulations, hospital conditions of participation, and accreditation standards.

• Participates and leads the organization's efforts to prepare for, take part in, and respond to any necessary follow-up of both announced and unannounced regulatory body site visits.

• Informs staff regarding hospital accreditation and licensure standards and regulations.

• Works with policy owners to facilitate policies are compliant with regulatory bodies.

• Provides regulatory consultation for internal customer projects to ensure that they are consistent with the regulations.

• Develops, maintains, and documents in requisite databases in order to track activities and ensure continuous process improvement and efficiency within the organization and department.

• Demonstrates understanding of concepts, methods, techniques and principles needed to accomplish job responsibilities such as New York Department of Health, The Joint Commission (TJC) and Center for Medicare and Medicaid Services (CMS) regulations.

• Other Quality and Regulatory Affairs related duties as assigned by Nursing Leadership.

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