Education and Work Experience:

• Bachelor's Degree in a healthcare-related field or equivalent combination of education/related experience: Required
• Master's Degree: Preferred
• Five years' technical experience: Preferred
• One year's leadership experience: Preferred

Essential Functions:

• Develops programs/processes related to Quality Management. Responsibly directs and monitors personnel in the performance if quality and risk management activities in order to ensure patient care , safety and performance improvement. Instructs new professional and ancillary personnel on job duties and assignments. In the absence of the Director, provides guidance to the department, as requested by the Director
• Participates in quality committees with accountability for distribution of organizational communication. Assures appropriate education of Directors on new measures and by Adventist Health targets and definitions. Develops, implements, and maintains departmental policies and procedures for Organizational Performance as assigned by Director.
• Collaborates with, facilitates, and serves as a resource to Performance Improvement Teams. Jointly develops, implements, and maintains the Performance Improvement functions required by TJC in conjunction with the Director of Organizational Performance and attends Medical Staff committees as requested by the Director. Prepares quarterly and Annual Team reports for those PI Teams assigned. Provides annual reports regarding performance Improvement and Quality programs.
• Assists with Peer Review system and functions as resource, teaching others and preparing requested reports. Oversees the use of the system by peer review staff. Ensures the compatibility of data needs versus ease of entry needs by staff. Coordinates use with the medical staff office.
• Assists with Onet program, assures all requirements are met for validation process and that updates are completed within specified timeframes.
• Performs other job-related duties as assigned.

Organizational Requirements:

Adventist Health is committed to the safety and wellbeing of our associates and patients. Therefore, we require that all associates receive all required vaccinations, including, but not limited to, measles, mumps, flu (based on the seasonal availability of the flu vaccine typically during October-March each year), COVID-19 vaccine (required in CA, HI and OR) etc., as a condition of employment, and annually thereafter. Medical and religious exemptions may apply.