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Baptist Memorial Health Care · 1 week ago

Director-Quality & Compliance

New Albany, MS

Full-time

Onsite

Lead/Staff, Director/Executive

5+ years exp

Baptist Memorial Health Care is focused on ensuring quality and compliance within the hospital. The Director of Quality & Compliance is responsible for managing quality, patient safety, and medical staff credentialing activities, while developing strategies to improve outcomes and mitigate risks.

GovernmentHealth CareHospitalMedicalNon ProfitNursing and Residential CareRehabilitationWellness

Responsibilities

Responsible for all quality, compliance, patient safety, and medical staff credentialing activities within the hospital

Develops and implements strategy relating to matters of quality, outcomes and experience, and for identifying and mitigating risks to the patient and/or staff

Creates and manages major elements of the Strategic A3s relating to Right Care

Oversees all activities relating to complying with the requirements for hospital accreditation and licensure

Interfaces directly with JCAHO, the Mississippi Department of Health, and CMS as necessary

Oversees the hospital’s benchmarking programs

Is the hospital’s point of contact and manages the hospital’s engagement with Leapfrog, Premier, Quest, and Vizient

Designs programs and oversees the orientation and education of staff in matters of quality, regulatory compliance, patient safety, and patient experience

Is the primary liaison with the medical staff in matters of quality, regulatory compliance, investigation of claims and actions, and patient experience

Is the hospital’s representative to the Peer Review, and Quality Committees

Assists the medical staff office in matters relating to credentialing, the delineation of privileges, the medical staff bylaws and rules and regulations, and the disciplinary process

Is the primary interface with the corporate departments responsible for quality, compliance, and patient safety at the system level

Participates in community health activities including mortality review, planning for events impacting the health status of the citizenry, and in the adoption and administration of regulations affecting the hospital

Prepares and oversees the budget for the assigned areas of responsibility

Recommends programs and expenditures that can influence outcomes, experience, and/or the mitigation of risk

Develops and administers policy relating to quality, compliance, and patient safety

Qualification

Quality ManagementCompliance OversightPatient SafetyHealthcare ManagementRisk ManagementClinical ExperienceCertified Professional in Healthcare QualityCommunication SkillsOrganizational SkillsProblem Solving

Required

Five (5) years of clinical experience as a registered nurse or healthcare management with previous experience in Quality, Risk and/or Compliance

5 years experience in quality, risk or compliance; baccalaureate, associate or diploma degree in a health-related field, nursing preferred; Certified Professional in Healthcare Quality (CPHQ)

Completion of a baccalaureate, associate or diploma degree in health-related field

Knowledge of licensure and accrediting requirements; ability to communicate and work effectively with medical staff, department heads and administration; excellent organizational skills and problem solving abilities