Manager, Regulatory Compliance - Quality Assurance
Legal and Compliance
CHRISTUS Spohn Hospital Corpus Christi Shoreline
600 Elizabeth Street
Corpus Christi, TX 78404
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In collaboration with other clinical leaders, is responsible for ensuring that patient care is delivered within the framework of evidence-based practice throughout the health system continuum and for understanding existing and emerging requirements in healthcare quality, safety, service/experience and operational improvements. Under the direction of the Chief Medical Office and in collaboration with CHRISTUS Health & CHRISTUS Spohn Health System senior leaders, facility leaders, physicians, and the Board of Directors, collaborates with other leaders to develop the strategic direction and system-wide planning for the overall delivery of high quality patient care across the continuum of health care service specifically related to improving organizational performance. Responsible for the design, implementation, tracking, and reporting of clinical quality of care in alignment with the corporate strategies for performance improvement throughout the Spohn Region. Possesses the skills to direct in redesign of clinical processes across the continuum of care, i.e. have the creativity to design and orchestrate innovative clinical transformation.
- Bachelor’s degree in Health Care Administration, Nursing or a relevant clinical discipline with evidence of additional training in PI and Quality required.
- Master’s degree in Nursing or other healthcare related profession strongly preferred.
- Language Ability: Ability to read, analyze and interpret general business periodicals, professional journals, technical procedures, or governmental regulations. Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to common inquiries or complaints from groups of managers, clients, customers, and the general public.
- Math Ability: Ability to work with mathematical concepts such as probability and statistical inference. Ability to apply concepts such as fractions, percentages, ratios and proportions to practical situations.
- Reasoning Ability: Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.
- Computer Skills: Must be proficient in use of Microsoft Excel, Word, Access, PowerPoint, and the Internet.
- Demonstrated hands-on leadership and operational responsibility in a large/complex healthcare environment.
- Demonstrated success in collaborating with other key leaders. Understanding of regional operating unit leadership issues, concerns, and challenges.
- Demonstrated ability to plan, schedule, develop task/time lines.
- Demonstrated ability to read and comprehend patient safety, complex standards and regulations.
- Demonstrated ability to manage and define processes and projects to achieve identified goals within specified timelines.
- Demonstrated ability to manage records, files, documentation both hard and electronic.
- Demonstrated ability to achieve continuous survey readiness.
- Demonstrated ability to integrate and interpret data from diverse sources addressing issues of high complexity.
- Demonstrated ability to develop working relationships with customers (i.e. associates, directors, vice presidents, physicians)
- Must demonstrate and maintain knowledge of regulatory and accrediting agencies' standards related to both hospital and physicians' services.
- Proficient in Windows-based operating software and systems that include MS Word, MS Excel, MS Access, and MS Power Point.
- Knowledge of clinical quality, patient safety, satisfaction performance measures and indicators, and experience in project development, project management with strong analytical skills.
- Excellent written and oral communication and presentation skills required.
- Must promote and demonstrate a logical, systematic and non-judgmental approach to case review and be able to formulate concise and relevant summaries with competing factors.
- Ability to work under minimal supervision, ability to adapt quickly to changes with the work environment required.
- Is solution driven and is able to address situations with tact and diplomacy.
- Minimum of five (5) years of progressive Quality Management, Joint Commission survey readiness, or administrative experience in a clinical setting in a hospital or health system.
- Minimum of five (5) years of experience in a strategic quality position of a complex health care environment.
- Current Certified Professional in Health Care Quality (CPHQ) required.
- Current Texas license in a relevant clinical discipline is strongly preferred.