Internal Audit Director - FT - Days - Corporate Compliance @ MV

El Camino Health • Mountain View, CA

5d • $91 - $136 • Onsite

About The Position

The Director Quality and Public Reporting provides leadership to ensure high quality, safe care by ensuring organizational systems and processes comply with the Joint Commission accreditation standards, state and federal regulations and other identified standards. Leads, facilitates and supports activities relating to licensing, accrediting, and regulatory compliance. Monitors and improves quality outcomes for all patient populations. Collaborates with senior leadership, service-line directors, department leaders, clinical and medical staff to improve quality outcomes. Provides oversight, education and guidance to meet regulatory standards and assure continued survey readiness. Improves operational efficiency of regulatory and quality metric reporting and addresses identified opportunities to improve clinical quality across the enterprise. Provides guidance, direction and expertise to assess and improve quality of care provided across the enterprise. Provides oversight and input to the policy and procedure review process assuring that procedures are up to date and reflect evidence-based best practices. This Director will play a key role in organizing clinical and medical staff teams to accomplish the organizational and quality goals. Provides oversight and guidance to staff addressing regulatory and public reporting requirements. Director will work coordinators, leaders and managers to maintain certifications and improve care under Joint Commission Disease-specific certification.

Requirements

• Degree in Nursing or Clinical healthcare related field.
• Minimum of 5 years clinical experience.
• A minimum of 5 years management experience and 3 years recent experience in Joint Commission Survey preparation and Continuous Survey Readiness activities .
• Extensive knowledge of accreditation standards applicable to Hospital, Long Term Care, and Behavioral Health.
• Recent experience with CMS, State and Joint Commission surveys.
• Experience in leading change, designing and improving workflow/work processes.
• Experience and credentials in Process Improvement Techniques (PDCA, Lean Six Sigma),
• Experience in staff education and strong communication and presentation skills.
• Demonstrated abilities in areas of project management, analytical interpretation and critical thinking.

Nice To Haves

• Masters’ degree in Nursing or healthcare-related field, preferred
• 5 years of clinical operations management experience preferred
• Current license as a Registered Nurse in the State of California, preferred
• Certified Professional in Healthcare Quality (CPHQ), preferred

Responsibilities

• Serves as the primary contact for all regulatory agencies: Supervises the administrative liaison when regulatory agencies are on-site, the Manager of Accreditation and Regulatory Reporting
• Assists the Sr. Director with development of and compliance with CMS QAPI standards, works to implement the Performance Improvement and Patient Safety Plan, supports the clinical care contract evaluation process.
• Consults with organizational leaders regarding regulations and means to maintain compliance.
• Ensures that leaders and employees are knowledgeable of regulatory standards.
• Educates staff on changes in legislation and requirements related to regulatory accreditation and licensing issues.
• Assures continuity and consistency in compliance with regulatory issues across the organization by evaluating the impact of specific issues.
• Collaborates with clinical and medical staff leaders to develop and implement corrective action to minimize negative impact and maximize learning.
• Leads the Manager of Accreditation and Regulatory Reporting to prepare for surveys and inspections for all regulatory agencies.
• Maintains relationship with representatives of regulatory agencies.
• Ensures the organization monitors against regulatory standards to create a culture of ongoing compliance and patient safety.
• Manages staff to improve operational efficiency in public reporting, improving clinical core measure outcomes, and improve results in Patient Blood Management, Bariatric program results and NSQIP outcomes.
• Provides education and direction to enterprise managers and directors in addressing quality improvement across all service lines

Benefits

• El Camino Health will provide reasonable accommodations to qualified individuals with a disability if that will allow them to perform the essential functions of a job unless doing so creates an undue hardship for the hospital, or causes a direct threat to these individuals or others in the workplace which cannot be eliminated by reasonable accommodation.

What This Job Offers

• Job Type: Full-time
• Career Level: Director
• Education Level: Associate degree