Demo

Manager Quality & Regulatory Affairs

Silver Cross Hospital
Lenox, IL Full Time
POSTED ON 4/17/2025
AVAILABLE BEFORE 5/7/2025

Silver Cross Hospital is an extraordinary place to work. We're known for our culture of excellence and delivery of unrivaled experiences for our patients, their families, the communities we serve...and for each other. Come join us! It's the way you want to be treated.

Position Summary : Reporting to the Director of Quality and Patient Safety, this position serves as a managerial support to clinical quality and performance improvement activities as well as facilitating compliance in accordance with the regulatory agencies; CMS, Joint Commission, Illinois Department of Public Health, QIO, OSHA, etc.. policies, procedures, mission, and strategic plan of Silver Cross Hospital.

Essential Duties and Responsibilities :

  • Collaborates with key stakeholders to develop and monitor performance / quality improvement actions to contribute to quality -driven outcomes
  • Applies principles of performance improvement to identify areas of opportunity, facilitates improvement strategies based on evidence based, best practice, and assists in organization wide monitoring and evaluation activities to sustain desired performance and outcomes.
  • Ensures organizational wide compliance with outside regulatory entities such as IDPH, JC, OSHA, etc..
  • Possesses current knowledge of regulatory requirements as well as ensuring implementation and compliance within the organization :

Leads regulatory survey preparation through meetings, unit rounding, distribution of information

  • Leads or provides direction for in-house surveys
  • Support data needs for regulatory quality reporting requirements and state, federal and other voluntary reporting agency quality initiatives.
  • Ensures compliance with regulatory submission for the Joint Commission, CMS, core abstraction
  • Ensures policies are reflective of the current standard requirements
  • Assures compliance with data submission requirements as outlined by IPDH, Joint Commission, CMS, etc.
  • Provides oversight of the Stroke Program. :
  • Assists in identifying trends in patient care issues and outcomes for the Stroke patient population and supports the implementation of recommended improvements

  • Assures compliance with data submission requirements as outlined by IPDH, Joint Commission,
  • Oversees compliance with regulatory submission for the Joint Commission, CMS, core abstraction
  • Ensures policies are reflective of the current standard requirements
  • Promotes a clean and safe environment of care, utilizing the SAFE error prevention habits
  • Provides the highest standard of privacy and confidentiality in matters involving patients, coworkers, and the hospital by abiding by the Standards of Conduct.
  • This document represents the major duties, responsibilities, and authorities of this job, and is not intended to be a complete list of all tasks and functions. Other duties may be assigned
  • Required Qualifications :

    Education and Training :

  • Bachelor's degree in nursing or other healthcare related field is required; Master's Degree in Nursing or other healthcare related field is highly preferred.
  • CPHQ certification highly preferred.
  • Work Shift Details : Days, Days

    Department :

    QUALITY RESOURCE MANAGEMENT

    Benefits for You

    At Silver Cross Hospital, we care about your health and well-being and that is why we work hard to provide quality and affordable benefit options for you and your eligible family members.

    Silver Cross Hospital and Silver Cross Medical Groups offer a comprehensive benefit package available for Full-time and Part-time employees which includes :

  • Medical, Dental and Vision plans
  • Life Insurance
  • Flexible Spending Account
  • Other voluntary benefit plans
  • PTO and Sick time
  • 401(k) plan with a match
  • Wellness program
  • Tuition Reimbursement
  • Silver Cross Management Services Org. - Premier Suburban Medical Group benefits offered to Full-time and Part-time employees include :

  • Medical, Dental and Vision plans
  • Life Insurance
  • Health Savings Account
  • Flexible Spending Account
  • Other Voluntary benefit plans
  • PTO bank
  • 401(k) plan with a match
  • Wellness program
  • Tuition Reimbursement
  • Registry employees who meet eligibility may participate in one of our 401(k) Savings plan with a potential match. However,registry employees are ineligible for Health and Welfare benefits.

    The expected pay for this position is listed below :

    42.88 - $54.67

    The final offered salary will take several factors into consideration, including but not limited to : licensure, certifications, work experience, education, knowledge, demonstrated abilities, internal equity, market data, and more.

    Salary : $43 - $55

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