PURPOSE STATEMENT:

Provide support activities for the departments of Risk Management and Performance Improvement.

ESSENTIAL FUNCTIONS:

Monitor and audit program components to ensure compliance with contracts, licensing and accreditation standards. Complete quality analysis reports and identify recommendation for improvement. Assist in the development and oversight of program improvement initiatives and corrective action plans. Assist in the attainment and renewal of accreditation and licensing for the facility. Assist in maintaining accreditation compliance, patient safety goals and other state or licensing requirements. Assist in the development and oversight of program improvement initiatives and corrective action plans. Assist in the attainment and renewal of accreditation and licensing for the facility. Facilitate document processing between managers and committees. Record and maintain committee meeting minutes, performance improvement and risk management documentation. Maintain and update electronic and physical database. Assist in project implementation and system-wide education and compliance initiatives including compliance with State Licensing and CMS regulatory requirements Track projects as assigned throughout the facility, which may include but is not limited to quality council, policies and procedures, safety committee, departmental monitors, board monitors and graphs. Travel as needed to off-site programs to provide assistance with investigations, compliance matters, and training as deemed necessary by the Director of Risk Management. Provide on-call assistance as needed related to investigations according to company policy/procedure and licensing agencies.