Job Description

JOB SUMMARY:
Partners with the GPA Director of Quality/Regulatory to provide oversight and responsibility for the resources, education, auditing, and corrective action planning required to meet regulatory compliance and accreditation objectives within the Quality Management System of GPA Carle Health, Hospitals, Behavioral Health, and applicable entities within the GPA Carle Physician Group (CPG). Partners with and through leadership, medical staff, nursing staff and the ancillary departments to develop their understanding and accountability for regulatory compliance.
Coordinates the development of policies/procedures and strategies to ensure compliance with federal and state regulatory requirements. Objectively and systematically assesses, monitors, evaluates and promotes the improvement of processes that affect the quality of patient care, ensuring regulatory compliance with the acute care hospital standards and critical access hospital standards.

EDUCATIONAL REQUIREMENTS
Associates Degree in any healthcare field

CERTIFICATION & LICENSURE REQUIREMENTS
Basic Certificate in Quality & Safety (IHI) within 1 year of hire.

EXPERIENCE REQUIREMENTS
Minimum of three years of recent experience in Accrediting Organization preparations and coordination in a hospital setting

SKILLS AND KNOWLEDGE
Knowledge of continuous quality improvement theory and statistics, and a strong grasp of the principles and skill set of nursing clinical processes, along with a depth of knowledge of patient safety principles. Strong human relations, influencer, leadership, teamwork
management, interpersonal, and communication skills. Ability to facilitate diverse groups/teams. Extensive knowledge of Accrediting Organization standards and requirements. Ability to analyze, interpret and display data. Excellent organizational skills. Advanced presentation skills. Knowledge of quality improvement tools and techniques. Proficiency in Windows environment, MS Word, Excel, and PowerPoint; and ability to readily develop proficiency in any software programs necessary to the position.

ESSENTIAL FUNCTIONS:

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