Job Summary
Responsible for the coordination of all organization wide mock tracer and other process improvement activities including facilitating, initiating, providing support, and education. Ensures that the organization is in compliance with standards of regulatory and accreditation agencies (i.e. TJC, DNV, CMS, TDSHS, and other hospital licensing) at all times. Prepares, analyzes, and compiles statistics for reports. Assists to facilitate committee meeting as needed; assists with ethics and compliance issues as needed, assists in the workup and investigation of patient's complaints, and performs other duties as assigned.

Minimum Qualifications

Degree: Bachelors Degree required (Nursing or other Allied Health preferred).

Licenses & Certification: Certified Professional for Healthcare Quality or Quality Audits required or within one (1) year of employment

Work Experience: Five (5) years of experience in Quality Management or Accreditation

Management Experience: Five (5) years of Project Management preferred

Communication Skills:
Above Average Verbal (Heavy Public Contact)
Writing / Correspondence
Writing / Reports

Proficiencies: MS Excel, MS Power Point, MS Word, Personal Computer

Job Attributes

Knowledge/Skills/Abilities: Analytical Abilities, Design Knowledge and Skills, Mathematics, Medical Terminology Knowledge, Transcription

Work Schedule: Weekends, Holidays, Flexible, Travel, Eligible for Telecommute

Other Requirements: May require extended hours in addition to weekends/holidays for special projects.

Equipment Operated: Personal Computers, printers, copiers, fax machines, window-based software programs (excel, power point, word etc.)