The Assistant Director of Quality, Regulatory Affairs and Accreditation will assist with the Director of Quality, Regulatory Affairs and Accreditation in the strategic management and planning for Joint Commission Accreditation and accreditation related activities for all clinical services throughout Cook County Health (CCH), including hospitals, clinics, behavioral health centers and ambulatory surgery centers. Works with the Director to sets guidelines to meet requirements for Joint Commission Accreditation leading to successful accreditation for all entities within the health system. Assists the Director with the development and maintenance of a comprehensive accreditation project plan that includes standards education, prioritized interventions and on-going monitoring for standards compliance as established by Joint Commission for all accreditation requirements. Assists the director with the development and management of a plan to assure compliance with Centers for Medicare and Medicaid Services (CMS) Conditions of Participation. Assists in Coordinating efforts to earn outstanding clinical performance and a positive customer experience as required for accreditation. Assists in coordinating efforts to assure regulatory compliance with standards established by our managed care partners.
This position is exempt from Career Service under the CCH Personnel Rules.
Establishes guidelines to meet Joint Commission accreditation requirements
Develops and leads a regulatory survey readiness program in support of the organization's mission, values and business objectives
Develops and maintains a comprehensive project plan linked to standards with on-going monitoring and reporting to senior management
Serves as the System's resource in questions related to accreditation and to CMS standards
Works with CCHHS senior management and clinical staff in leading and managing all aspects of the accreditation process and standard adherence
Coordinates activities with subject matter experts and unit business owners
Conducts training and coaching to support understanding of accreditation standards and requirements
Develops and maintains plans to assure compliance with regulatory requirements of managed care plans
Develops and manages audit activities to ensure compliance with accreditation standards and develops and maintains a dashboard to demonstrate ongoing compliance
Facilitates communication of information among governance committees and serves as liaison on accreditation issues and changing standards
Maintains accreditation and audit document library
Maintains and updates policy library
Performs other duties as they might be assigned
Bachelor's degree from a four-year accredited university
Successful completion of the accreditation process resulting in a fully accredited designation
Five (5) years of experience in management or leadership role within a large hospital or healthcare system
Seven (7) years of experience with accreditation and regulatory survey process, development and follow-up of corrective plans
Proficiency using Microsoft Office (Outlook, Excel, Word, and PowerPoint)
Five (5) years of experience in developing and implementing an accreditation plan in healthcare environment
Master's or similar degrees in healthcare administration, such as MBA, MHA, MS, MPH, or MPA
Additional certification in healthcare quality management from a recognized organization
Expert knowledge of regulatory environment including Joint Commission, CMS, National Committee for Quality Assurance (NCQA)
Knowledge, Skills, Abilities and Other Characteristics
Excellent verbal and written communication skills necessary to communicate with all levels of staff and a patient population composed of diverse cultures and age groups
Excellent program development, management and leadership skills
Strong customer service and empathy skills
Must be able to work flexible hours
Must be able to travel throughout Cook County
Performs other duties as assigned
MUST MEET ALL REQUIRED QUALIFICATIONS AT TIME OF APPLICATION FILING.
When applying for employment with the Cook County Health & Hospitals System, preference is given to honorably discharged Veterans who have served in the Armed Forces of the United States for not less than 6 months of continuous service
To take advantage of this preference a Veteran must :
Meet the minimum qualifications for the position.
Identify self as a Veteran on the employment application by answering yes to the question by answering yes to the question, "Are you a Military Veteran?"
Attach a copy of their DD 214, DD 215 or NGB 22 (Notice of Separation at time of application filing. Please note: If you have multiple DD214s, 215s, or NGB 22S, Please submit the one with the latest date. Coast Guard must submit a certified copy of the military separation from either the Department of Transportation (Before 9/11) or the Department of Homeland Security (After 9/11). Discharge papers must list and Honorable Discharge Status. Discharge papers not listing an Honorable Discharge Status are not acceptable
A copy of a valid State ID Card or Driver's License which identifies the holder of the ID as a Veteran, may also be attached to the application at time of filing.
If items are not attached, you will not be eligible for Veteran Preference
VETERANS MUST PROVIDE ORIGINAL APPLICABLE DISCHARGE PAPERS OR APPLICABLE STATE ID CARD OR DRIVER'S LICENSE AT TIME OF INTERVIEW.
Medical, Dental, and Vision Coverage
Basic Term Life Insurance
Pension Plan and Deferred Compensation Program
Paid Holidays, Vacation, and Sick Time
You may also qualify for the Public Service Loan Forgiveness Program (PSLF)
Degrees awarded outside of the United States with the exception of those awarded in one of the United States' territories and Canada must be credentialed by an approved U.S. credential evaluation service belonging to the National Association of Credential Evaluation Services (NACES) or the Association of International Credential Evaluators (AICE). Original credentialing documents must be presented at time of interview.
*Please note all offers of Employment are contingent upon the following conditions: satisfactory professional & employment references, healthcare and criminal background checks, appropriate licensure/certifications and the successful completion of a physical and pre-employment drug screen.
*CCHHS is strictly prohibited from conditioning, basing or knowingly prejudicing or affecting any term or aspect of County employment or hiring upon or because of any political reason or factor.
COOK COUNTY HEALTH AND HOSPITALS SYSTEM IS AN EQUAL OPPORTUNITY EMPLOYER
ABOUT COOK COUNTY HEALTH (CCH)
The Cook County Health’s mission is to deliver integrated health services with dignity and respect regardless of a patient’s ability to pay; foster partnerships with other health providers and communities to enhance the health of the public; and advocate for policies that promote the physical, mental and social wellbeing of the people of Cook County.
CCH is comprised of two hospitals, John H. Stroger, Jr. Hospital and Provident Hospital, a robust network of more than a dozen community health centers, the Ruth M. Rothstein CORE Center, the Community Triage Center, the Cook County Department of Public Health, Cermak Health Services, which provides health care to individuals at the Cook County Jail and the Juvenile Temporary Detention Center, and CountyCare, a Medicaid managed care health plan.
The system cares for more than 300,000 patients each year and its physicians are experts in their fields, committed to providing their patients with comprehensive, compassionate and cutting-edge care. Today, CCH is transforming the provision of health care in Cook County by promoting community-based primary and preventive care, growing an innovative, ...collaborative health plan and enhancing the patient experience.
COOK COUNTY HEALTH IS AN EQUAL OPPORTUNITY EMPLOYER