Facilitates and coordinates hospital-wide quality management programs to ensure compliance with Joint
Commission and other regulatory requirements. Facilitates compliance with core measures. Facilitates
Hospital Patient Safety/Quality Council meetings. Prepares and presents quality reports for Medical Executive
Committee and Hospital Governing Board. Facilitates hospital risk management activities to include root cause
analysis as required. Responsible for hospital complaint and grievance process. Manages hospital occurrence
reporting process. Prepares and presents complaint and occurrence analysis reports for Hospital Quality
Council, Medical Executive Committee, and Governing Board. Coordinates Medical Staff Peer Review process.
Develops and manages the department budget.

Required Skills
Requires critical thinking skills, decisive judgment, and the ability to work with minimal supervision. Must be able to work in a stressful environment and take appropriate action.

Drag Edit DeleteMinimum Education
Bachelor’s degree is required
Masters degree is preferred
RN Nursing License is required
Equal opportunity and affirmative action employers and are looking for diversity in candidates for employment: Minority/Female/Disabled/Protected Veteran