Quality/Regulatory Compliance Manager

Fields marked with an asterisk (*) must be filled out before submitting.

DEPARTMENT
Quality

EMPLOYMENT TYPE
Full Time

JOB RESPONSIBILITIES

GENERAL

  • Preparation for and coordination of regulatory surveys
  • Regulatory survey response and compliance
  • Regulatory self-reporting activities and follow-up
  • Quality Review Report review and follow-up
  • Failure Mode and Effect Analysis and Root Cause Analysis investigation and reports
  • Complaints: investigation and follow-up
  • Patient satisfaction surveys
  • Beta HEART program

COMMITTEES

  • Quality and Safety Leadership Committee
  • Continuous Quality Improvement Program
  • Nurse Advisory and Regulatory Compliance Committee
  • Board of Directors Quality Committee
  • Peer Review chart prep and committee participation
  • Medication Error Reduction Program
  • Falls Committee
  • Wound Care Committee
  • Fire, Life, Safety/Emergency Operations Committee
  • Team Walk Rounds

DATA COLLECTION AND REPORTING

  • Emergency Department Transfer Communication
  • Department Dashboards
  • Patient Surveys
  • QNET, MBQIP, NHSN, HSAG, IQR
  • Ongoing Professional Practice Evaluation

ADDITIONALLY

  • Department Manager meeting
  • New Employee Orientation – Quality
  • Policy review and development
  • FLEX and SHIP Grant management

EDUCATION/EXPERIENCE
Bachelors degree preferred or three to five years experience in the clinical health care field.

CERTIFICATES, LICENSES, REGISTRATIONS
Appropriate licensure: Current RN License in California required.
CPHQ certification required.

EDUCATION

LICENSES AND CERTIFICATIONS

EMPLOYMENT HISTORY

I hereby certify that I have been informed of the duties of the position that I am applying for and that the information of this application is correct and complete to the best of my knowledge. I agree to have any of the statements checked by the Mountains Community Hospital unless I have indicated to the contrary. I understand and agree that, if offered a position, I will be required to take and pass a physical examination including drug testing before I will be allowed to commence work. Further I understand that falsification or omission of any material information on this application may be considered sufficient cause for immediate termination. I agree that, if employed, I will abide by and observe all policies, procedures, rules and regulations established by Mountains Community Hospital and understand that my employment is at will, if hired.