Director, Quality and Accreditation - LV Durango Family Medicine Clinic - Full T

The Director is responsible for designing, implementing, and maintaining programs and practices to ensure the organization complies with applicable regulations and accreditation standards. The Director provides day-to-day operational leadership and oversight of regulatory compliance to improve patient safety and reduce clinical risk. The Director acts as a resource for the organization regarding issues of quality improvement and regulatory standards and identifies strategic initiatives to support the organization's goals.

As a leader in the Culinary Health Operations, the Director is responsible for designing, implementing, and maintaining programs and practices to ensure the organization complies with applicable regulations and accreditation standards. The Director provides operational leadership and oversight of regulatory compliance to improve patient safety and reduce clinical risk. The Director acts as a resource for the organization regarding issues of quality improvement and regulatory standards and identifies strategic initiatives to support the organization's goals. The Director will report directly to the Executive Administrator, Culinary Health Operations and will be responsible for covering all Culinary Health Center locations.

Essential Duties:

• Designs, implements, and maintains programs and practices to ensure the organization complies with, DNV, TITLE 22, CMS, and other applicable State and Federal regulations and accreditation standards.
• Oversees regulatory body surveys, i.e. State licensing Reviews, AAAHC Surveys.
• Stays current with AAAHC, State, and Local standards and educates facility staff about standard requirements and changes as they occur.
• Identifies, develops, and evaluates quality improvement initiatives' particularly as they relate to regulatory programs
• Evaluates effectiveness of corrective actions for identified problems and continuous quality improvement activities.
• Serves on committees, task forces, and peer networks as appropriate.
• Trains and develops other departmental personnel in quality improvement and regulatory oversight, including announced and unannounced mock surveys
• Ensures compliance with Local, State, and Federal reporting guidelines; ensures accuracy of all data prior to reporting
• Directs performance improvement initiatives within the health center and system.
• Directs onsite survey processes with regulatory agencies, both announced and unannounced.
• Primary communicator with regulatory agencies.
• Communicates needs with administration and departmental leadership relative to implementation and compliance standards.
• Communicates with all accreditation agencies for any direction or questions relative to compliance or implementation as necessary to assure the center maintain survey readiness.
• Assures timely communication of regulatory and accreditation standards, changes and updates to appropriate staff.
• Perform other duties as assigned

Required Qualifications:

• Req Bachelor's Degree in Healthcare, Business, or related field

• Req 5 years Healthcare management experience with leadership roles in Clinical Operations, Quality and/or Regulatory Compliance

• Req Knowledge of governing regulatory requirements.
• Req Working knowledge of Microsoft Office Suite, including Outlook, Word, Excel, and PowerPoint.
• Req Excellent oral and written communication skills, with exemplary attention to detail.
• Req Excellent interpersonal skills to deal effectively and tactfully with people at all levels of management.

Preferred Qualifications:

• Pref Master's degree
• Pref Registered Nurse - RN (CA Board of Registered Nursing)
• Pref Registered Nurse (NV NSBN) CA RN license not applicable to Nevada Culinary Operations

Required Licenses/Certifications:

• Req Fire Life Safety Training (LA City) If no card upon hire, one must be obtained within 30 days of hire and maintained by renewal before expiration date. (Required within LA City only)
• Req Certified Professional in Healthcare Quality - CPHQ (NAHQ)

The annual base salary range for this position is $133,120.00 - $219,648.00. When extending an offer of employment, the University of Southern California considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate's work experience, education/training, key skills, internal peer equity, federal, state, and local laws, contractual stipulations, grant funding, as well as external market and organizational considerations.