• Job Type: Officer of Administration
• Bargaining Unit:
• Regular/Temporary: Regular
• End Date if Temporary:
• Hours Per Week: 35
• Standard Work Schedule:
• Building:
• Salary Range: $110,000-$125,000
  The salary of the finalist selected for this role will be set based on a variety of factors, including but not limited to departmental budgets, qualifications, experience, education, licenses, specialty, and training. The above hiring range represents the University’s good faith and reasonable estimate of the range of possible compensation at the time of posting.
  Position Summary
  Reporting to and working under the guidance of the Director for Quality Regulatory Compliance, the Quality Improvement & Regulatory Compliance (QI & RC) Specialist will support the coordination, assessment, monitoring, and documentation of a variety of regulatory compliance activities to ensure high-quality and safe care is delivered to our patients in accordance with meeting or exceeding pertinent regulatory requirements.
  The QI & RC Specialist will work collaboratively with various levels of leadership within the Faculty Practice Organization (FPO) as well as managers and staff throughout the organization. The successful candidate will be exposed to a variety of departments throughout the FPO in the promotion of operations, quality improvement, and regulatory compliance initiatives. Responsibilities assigned may be related to but not limited to Patient Centered Medical Home (PCMH), The Joint Commission (TJC), American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF), New York State Department of Health (NYS DOH), United States Drug Enforcement Agency (US DEA), Centers for Medicare and Medicaid Services (CMS), Accountable Care Organization (ACO and other accreditation and regulatory agencies.

Responsibilities

• Maintains ongoing compliance with Joint Commission, state, and federal standards; oversight responsibility for all regulatory body surveys, i.e., Joint Commission, State licensing Reviews, CMS Validation Surveys, health department, local regulatory reviews (fire marshal), and any other regulatory activity that may involve the facility. This responsibility includes staying current with Joint Commission, state, and local standards; educating facility staff about standards; and preparing the facility for such accreditation surveys.
• Plans and coordinates quality and regulatory compliance activities, including but not limited to site visits and mock surveys to assure appropriate, high-quality quality and regulatory-compliant healthcare delivery. This includes the development and implementation of Quality Assessment/Performance Improvement plans, the evaluation of the effectiveness of corrective actions for identified problems, and continuous quality improvement activities.
• Working knowledge of the New York Patient Occurrence Reporting and Tracking System (NYPORTS) regulatory reporting requirements.
• Utilize project management tools to promote timely progression and monitoring of project timelines and deliverables, as well as communicating challenges and results to project stakeholders.
• Serves as a resource in the delivery of tasks to advance the development and implementation of performance improvement and regulatory compliance programs in accordance with applicable local, state, and national standards, guidelines, and/or regulations.
• Participates in committees, task forces, and workgroups as assigned to represent Quality Improvement and Regulatory Compliance.
• Completes other tasks as assigned within scope of practice, expertise, and training.

Minimum Qualifications

• Requires a Bachelor’s degree in Nursing or equivalency
• 5 years minimum experience with at least 3 years of healthcare-related experience leading quality/performance improvement and Joint Commission/CMS survey preparation and coordination within a hospital, ambulatory care, ambulatory surgery, or clinic setting is required.
• An equivalent combination of education and experience may be considered.
• Current, unrestricted registered nurse license to practice in New York State
• Certification as a Certified Professional in Healthcare Quality (CPHQ) is required or obtained within 1 year of employment.
• Must possess strong project management, organizational, interpersonal, written, and oral skills.
• Must be computer and internet literate with knowledge of EMR systems and strong experience in MS Office, Project, Word, Teams, Excel, and PowerPoint.
• Candidate must be dependable, detail-oriented, effective team player with a strong service-minded work ethic.
• Experience interacting with all levels of faculty, management, and staff.
• Must be able to maintain the highest level of confidentiality and diplomacy at all times.
• Excellent customer service skills and operational experience.
• Ability to work within tight deadlines and manage multiple projects effectively.
• Must successfully complete training systems.

Preferred Qualifications

• Master’s degree in Public Health, Healthcare Administration, or other healthcare-related programs.
• Clinical degree RN, NP, PA, PharmD, or MD/DO preferred.
• Certification in Healthcare Compliance (CHC) or Lean Six Sigma is desirable.

Competencies

• Maintains ongoing compliance with Joint Commission, state, and federal standards; oversight responsibility for all regulatory body surveys, i.e., Joint Commission, State licensing Reviews, CMS Validation Surveys, health department, local regulatory reviews (fire marshal), and any other regulatory activity that may involve the facility. This responsibility includes staying current with Joint Commission, state, and local standards; educating facility staff about standards; and preparing the facility for such accreditation surveys.
• Plans and coordinates quality and regulatory compliance activities, including but not limited to site visits and mock surveys to assure appropriate, high-quality quality and regulatory-compliant healthcare delivery. This includes the development and implementation of Quality Assessment/Performance Improvement plans, the evaluation of the effectiveness of corrective actions for identified problems, and continuous quality improvement activities.
• Working knowledge of the New York Patient Occurrence Reporting and Tracking System (NYPORTS) regulatory reporting requirements.
• Utilize project management tools to promote timely progression and monitoring of project timelines and deliverables, as well as communicating challenges and results to project stakeholders.
• Serves as a resource in the delivery of tasks to advance the development and implementation of performance improvement and regulatory compliance programs in accordance with applicable local, state, and national standards, guidelines, and/or regulations.
• Participates in committees, task forces, and workgroups as assigned to represent Quality Improvement and Regulatory Compliance.
• Completes other tasks as assigned within scope of practice, expertise, and training