Ensures the hospital maintains high standards of patient care and safe conditions through compliance with regulatory and accreditation requirements and quality improvement and education. This role contributes to creating a safe and supportive environment for patients, staff, and visitors.

Education

Bachelor’s degree in Nursing, Public Health, or related field required or equivalent experience.

Experience

At least 3 years’ experience in a clinical position in a Joint Commission accredited hospital or other similar healthcare environment. At least 3 years’ experience in accreditation/regulatory/certification coordination and preparedness and/or risk management, performance improvement or patient safety. Experience with healthcare regulatory compliance, action planning, mock surveys and readiness planning.

Knowledge, Skills and Abilities

Excellent interpersonal communication skills necessary to interact effectively with a wide variety of constituents. Excellent organization, verbal and written communication, problem solving and team facilitation skills. Ability to exercise judgment in interpreting and applying standards, regulations, policies and procedures. Skill in providing consultation and coaching to hospital staff to ensure regulatory compliance.Skill in conducting investigations, including chart reviews, timelines, in order to address patient safety issues, grievances and civil rights complaints. Ability to facilitate improvement, specifically RCA’s, ACA’s and FMEA’s. Familiar with the Model for Improvement – PDSA.Skills in risk mitigation to lessen untoward financial impact to the hospital.Knowledge of medical terminology and navigation of electronic medical record.Ability to gather, create reports, interpret and analyze data.Skill in using a computer and a variety of personal productivity applications (Excel, PowerPoint, Outlook, etc.)Demonstrated skill in delivering educational and training materials to clinical and support staff teams.Knowledge of process improvement principles and ability to lead teams toward fixing reoccurring issues.Excellent organizational agility.

Licensures, Certifications

Certification in Patient Safety (CPPS) within 1 year; Certification in Healthcare Risk Management within 2 years (CPHRM)

Physical Requirements

Able to perform audits in clinical setting which includes long periods of standing, walking and bending. Ability to accompany surveyors throughout the campus.

Working Conditions

A combination of office environment and patient care areas.

Conditions of Employment

Reliable transportation.

Pay Range

$71,006.92 - $120,711.77

Final salary offer will be based on the candidate's qualifications, education, experience and alignment with our organizational needs.

COVID-19 Vaccination

All applicants must be fully vaccinated against Covid-19 or obtain a GBMC approved medical or religious exemption prior to starting employment at GBMC Healthcare, to include Gilchrist and GBMC Health Partners.

Equal Employment Opportunity

GBMC HealthCare and its affiliates are Equal Opportunity employers. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity and expression, age, national origin, mental or physical disability, genetic information, veteran status, or any other status protected by federal, state, or local law.