• Manager Quality, Regulatory Standards and Performance Improvement

    Job ID
    Regular Full-Time
  • Job Summary

    Manages the activities and functions of the Quality Improvement Department as it relates to Regulatory Standards and Performance Improvement. Provides guidance and direction for continuous improvement of quality of care, outcomes, safety and evidence-based practice across the continuum of care. Provides oversight for all Quality Improvement department functions including data collection, analysis, reporting and statistical display and Regulatory Standards compliance. Collaborates with the Chief Medical Officer (CMO). Monitors the performance of all quality councils and manages the preparation of reports including annual Quality Improvement Plan. Responsible for managing projects and initiatives of the healthcare system. Serves as a member on multiple committees and councils both internal and system wide. Responsible for multiple databases related to the tracking of quality and safety initiatives and manages action plans. Coordinates regulatory agency surveys. Maintains the Hospital Licensure and accreditation status. Serves in role of Survey Coordinator for the hospital for Joint Commission, Core measure reporting, Crimson and Mede analytics and Leapfrog Survey, Value Based Purchasing and CMS Star Reporting database. Provides coverage for the Infection Control Practitioner as necessary.


    RN with minimum of 5 years experience in the clinical area. Master’s degree or currently enrolled in Master’s program.


    Minimum of 3 years current quality leadership experience in an acute care hospital or hospital system environment


    In-depth knowledge of Joint Commission, NJDOH and Federal guidelines, regulations and standards, having prepared, and participated in State, Joint Commission, and CMS surveys.


    Knowledge of/or training in various Performance Improvement databases for internal and external reporting ( Quadramed, Leapfrog, IHI, AHRQ, Healthgrades, Joint Commission site, Hospital Compare (NJDHSS and CMS), Quality Net, Press Ganey.


    Proficient with MicroSoft (Word, Power Point, Excel, Outlook).


    Skilled in coaching, counseling, team building, and developing others


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