Overview Job Summary Participates in the planning, development, and implementation of goals and objectives related to accreditation, certification, regulatory, federal, and state requirements. Coordinates gathering and distributing of data in support of these clinical and regulatory programs. Conducts portions of the medical staff performance improvement process, including profiling with intent to maintain and improve quality of care and service. Provides consultation to physicians, staff, PI teams, and departments regarding improvement methodologies and processes. Reports to Director of Quality. Performs other duties as assigned. Responsibilities + Coordinates, implements and evaluates hospital and medical staff performance improvement activities. + Coordinates, implements and evaluates clinical quality initiatives for external comparative benchmarking. + Coordinates and facilitates the accreditation and regulatory compliance processes + Communicates effectively with physicians, staff, external entities. + Educates hospital staff and physicians regarding Performance Improvement tools and techniques. + Contributes to preparation for accreditation, certification, and surveys. + Complete chart abstraction and data analysis. + Assist with development, implementation, and evaluation of quality plan and performance improvement initiatives. + Directs community education and prevention programs. + Identify trends for strategic planning and performance improvement. + Completes assigned goals. Specifications Experience Minimum Required + 5 years of experience in a clinical setting. Prefer previous experience in quality and performance improvement. Preferred/Desired Education Minimum Required Preferred/Desired Training Minimum Required Preferred/Desired Special Skills Minimum Required Preferred/Desired Licensure Minimum Required + Registered Nurse Preferred/Desired REQNUMBER: 34917