Lead the ongoing readiness process ensure that the requirements and expectations of the Joint Commission DHS and title XXII (22) are fulfilled provide support to and provides leadership for a variety of projects within the Performance Improvement division Responsible for overall preparation and coordination for regulatory and integrity compliance as well as specific performance of the hospital quality strategic plan.
The Manager of Ongoing Readiness will collaborate and work in conjunction with Senior Management Administrative Directors Department Management Physicians and Staff to prepare for regulatory surveys such as JCAHO and the State Health Department. Responsible for data management analysis and visualization to support activities related to PI Risk Assessment and policy implementation. The Manager of Ongoing Readiness will report to the Director of Performance Improvement.
Requirements: Registered Nurse (RN) or eligible preferred Business Administration or other related field or equivalent training experience required - knowledge of State and Federal healthcare regulations including Title XXII (22) OSHA and JCAHO standards - minimum 5 years clinical experience in an acute care hospital or other healthcare setting - 2+ years of managerial or supervisory experience - 2+ years experience in regulatory readiness preparation - knowledge of the principles of regulatory compliance tracer methodology patient safety data management and computer methodologies to support data collection analysis and visualization - experience in performance improvement methodologies - good understanding of medical terminology microbiology nomenclature and the accreditation and licensure process - ability to effectively plan work activities establish work priorities multi-task workload manage confidential information and accommodate to changing work priorities - CPHQ preferred
• EDUCATION: Registered nurse, Bachelors Degree in Health Care Administration Masters Degree in related field preferred
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