Under the supervision of the Director of Quality Management, will oversee and coordinate continuous regulatory efforts and quality management. 

• Serves as a resource to hospital and medical staff departments to ensure the compliance with regulatory agency standards.
• Oversees and coordinates the collection, analysis, and data reporting related to ongoing regulatory compliance efforts.
• Responsible for supporting quality department scopes of work and providing leadership assistance and support for reaching established goals related to but not limited to performance improvement, OPPE/Peer Review, Quality Projects, Clinical Safety, and Value Based Quality Initiatives.

1. Provides strategic leadership to support the hospital and department in meeting and exceeding their commitment to continuous regulatory compliance, clinical safety, quality projects and ongoing performance improvement
2. Manages performance, including other management positions through staffing, competency assessment, performance evaluation, and disciplinary action.
3. Ensures orientation and training for employees, including physicians and other leaders related to assigned scopes of work
4. Provides direct oversight of regulatory readiness staff activities
5. Manages departmental budget and productivity standards
6. Interviews, selects, hires, and retains employees, including other management positions
7. Promotes, demotes, or transfers employees to meet organizational needs, including other management positions
8. Executes progressive discipline up to and including termination
9. Oversees the design, implementation and reporting related to performance improvement activities
10. Performs long range planning and overall direction setting at the departmental level
11. Responsible for department organizational structure and alignment to meet forecasted business needs
12. Responsible for development, implementation and interpretation of system policies within a major organizational/functional area or the development and review of system policies within a recognized discipline
13. Approves payroll and is responsible for accurate payment of employees, including other management positions

DCH Standards:

• Maintains performance, patient and employee satisfaction and financial standards as outlined in the performance evaluation.
• Performs compliance requirements as outlined in the Employee Handbook
• Must adhere to the DCH Behavioral Standards including creating positive relationships with patients/families, coworkers, colleagues and with self.

• Performs essential job functions in a manner that ensures the safety of patients, visitors and employees.
• Identifies and reduces unsafe practices that may result in harm to patients, visitors and employees.
• Recognizes and takes appropriate action to reduce risks and hazards to promote safety for patients, visitors and employees.

• Requires use of electronic mail, time and attendance software, learning management software and intranet.
• Must adhere to all DCH Health System policies and procedures.
• All other duties as assigned.

1. Licensed Registered Nurse with current licensure in the state of Alabama
2. Bachelor’s degree in nursing, health administration, public health, or business administration required
3. Minimum of 5 years’ experience in an acute healthcare setting required
4. Proven current regulatory compliance and survey processes skills required
5. Management or supervisory experience/training in a health related field required
6. Quality Management experience required
7. Ability to establish priorities, meet deadlines, and maintain proper productivity
8. Ability to form positive, collaborative relationships with hospital staff, physicians, patients, regulatory compliance consultants
9. Ability to problem solve in a proactive, creative manner, using sound judgement based on factual information and clinical knowledge
10. Must have excellent leadership skills
11. Ability to lead and actively participate in multidisciplinary teams
12. Excellent computer skills-proficient in MS office products preferred. Meditech experience is preferred.
13. Ability to work independently or within a team structure.
14. Excellent interpersonal skills and communication style
15. Must be able to read, write legibly, speak and comprehend English.
16. Expected to have the ability to read, analyze and interpret general business periodicals, professional journals, technical procedures or governmental regulations.

WORKING CONDITIONS

Work Context

• Able to maintain confidentiality
• Daily contact with others
• Able to work independently
• Regular work with work groups or teams
• Requires accuracy and attention to detail
• Physical presence onsite is essential
• Regular Schedule

Physical Factors

• Light work Exerting up to 20 pounds of force occasionally and/or a negligible amount of force constantly
• Average motor coordination
• Manual and finger dexterity important.
• Sitting involved in most job functions
• Hearing and vision must be normal or corrected to within normal range
• Able to perform the duties with or without reasonable accommodation

Environmental Factors

• May require wearing personal protective equipment
• Works primarily indoors