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Clinical Accreditation Manager, Quality
3 months ago
DescriptionWho you are:As a Clinical Accreditation Manager, Quality & Patient Safety for Catholic Medical Center (CMC), you will be supporting the Quality Management program and will be responsible for planning, developing, executing and coordinating an effective CMS accreditation program that provides action, oversight and follow up to ensure a culture of continuous survey readiness for all internal stakeholders and external entities. This includes, but is not limited to, the development, coordination and oversight of programs and projects that identify, prioritize, measure, analyze and improve key processes and outcomes, as well as day to day oversight and coordination of quality management functions. This is a full-time, exempt, benefitted position, Monday – Friday (day shift). Occasional requirements to cover special events, weekends, etc. What you’ll do:· Develop, promote and facilitate the organizational continuous readiness program that emphasizes quality and patient safety at the forefront of regulatory compliance with CMS Conditions of Participation and maintain compliance with related state and federal regulatory statutes and rules.· Act as a subject matter expert for standard interpretation and compliance for DNV and other accreditation and certification programs.· Provide guidance and support on identified accrediting and certification standards interpretation and other related regulatory requirements as they apply to organizational practice. · Collaborate and support identified DNV Chapter Leaders, leadership, medical staff leaders, and quality team to develop an effective program through understanding and execution of necessary actions that promote infrastructure development, process improvement and follow up, and sustained goal attainment. · Facilitate day to day operations of the Quality Management (QM) team to ensure organizational collaboration and support for all stakeholders. · Support QM functions of the Infection Prevention, Risk Management, Medical Staff Office and others to ensure communication, collaboration, and effective execution of system-wide initiatives.· Coordinate and oversee CMC’s event reporting system, including technology, workflow, education, and reporting.· Coordinate CMC’s policy and form management system to ensure integrity, version control and appropriate approval processes. Implements and interprets all policies, procedures, rules and regulations affecting areas of responsibility.QualificationsWhat you’ll bring:· School of Nursing Graduate/ Bachelor’s Degree in Nursing (BSN) required. Master degree in Management, Administration or Nursing preferred.· A minimum of five (5) years’ experience in a management or leadership role within a hospital or health system. · A minimum of ten (10) years clinical experience. · A minimum of five (5) years’ experience in Quality Management, Performance Improvement· A minimum of three (3) years’ experience related to accreditation and regulatory standards and processes. · Certification in Healthcare Quality (CPHQ) or additional certification in healthcare quality from a recognized organization strongly preferred· Certified Lean or Lean Six Sigma Green Belt preferred.Who we are:Catholic Medical Center (“CMC”) is a nonprofit, regional health system committed to delivering the highest quality and most advanced healthcare to patients across New Hampshire. CMC is the home of the nationally-renowned New England Heart & Vascular Institute, rated among the top cardiovascular programs in the country.We are driven by our mission to offer health, healing, and hope to every individual who seeks our care, and we live by our values of Respect, Integrity, Compassion, and Commitment.CMC is proud to be named to the Forbes list of America’s Best-in-State Employers for two consecutive years. This prestigious award is presented by Forbes and Statista, Inc., and is based on 2.1 million employer recommendations from employees working for companies with more than 500 employees in the United States.With our award-winning clinical programs, primary care network and dedication to community, CMC is fostering a healthier New Hampshire, every day.Catholic Medical Center is an equal opportunity employer and we embrace diversity. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity and expression, age, national origin, mental or physical disability, genetic information, veteran status, or any other status protected by federal, state, or local law.Job Field: Service PositionsJob Type: StandardSchedule: Full-timeShift: DayJob Level: Non ManagerEmployee Status: Regular
