Job Title: Director of Quality Management and Medical Staff (Registered Nurse License Required)

The primary responsibility of this position is to provide leadership for the Quality program for the facility. Direct all functions, programs, activities and staff of the Quality Resources, Patient Safety, Performance Improvement and Accreditation and Certification. In addition, oversee the Medical Staff/Credentialing department as well as processes within this department. Maintain compliance with regulatory standards, bylaws and policies

• Plans, directs, organizes and coordinates Quality Resources for the hospital and ASC.
• Must have an RN license
• Coordinate activities of the Continuous Quality Improvement Committee and associated activities.
• Supervise Quality Team and Credentialing Team.
• Oversee Peer Review process (OPPE/FPPE) for MEC workflow.
• Oversee Risk Management program
• Supervises Infection Control Program and Employee Health protocols and processes.
• Directs the Patient Safety function and program. Integrates those functions with Quality Improvement functions. Assures consistency and continuity among all activities. Ensures appropriate reporting of adverse events to external agencies as required.
• Directs all activities associated with accreditation and hospital licensure. Assures consistency and continuity among all activities.
• Develops and maintains professional, organizational, and community relationships.
• Presents a courteous and helpful demeanor, appropriate for ages, to all patients, visitors, other facility employees/medical staff members, or any other person and employee encounters while representing the facility.
• Maintains current knowledge related to applicable statutes, regulations, guidelines and standards necessary to perform job duties in accordance with the requirements of the Corporate Compliance Plan. Complies with the requirements of the Code of Conduct, Corporate Compliance Plan and Compliance Policies and Procedures, including training requirements. Participates in compliance activities under the direction of the Chief Nursing Officer, Hospital President, and Corporate Clinical Operation Leadership.
• Responsible for regulatory compliance as it pertains to all State and Federal regulatory agencies of the Hospital and ASC's Medical Staff Services.

PHYSICAL DEMANDS
- The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- While performing the duties of this job the employee is frequently required to sit, converse, and listen; use hands to touch, handle, or feel objects, tools or controls; and to reach with hands and arms. Specific vision abilities required by this job include close vision and the ability to adjust focus.
- The employee must be able to life and/or carry over 20 pounds on a regular basis and be able to push/pull over 25 pounds on a regular basis.
- The employee must be able to stand and/or walk at least five hours per day.

Leader - Inspires teammates to follow them
Detail Oriented - Capable of carrying out a given task with all details necessary to get the task done well

Ability to Make an Impact - Inspired to perform well by the ability to contribute to the success of a project or the organization
Growth Opportunities - Inspired to perform well by the chance to take on more responsibility

Registered Nurse (preferred)