ESSENTIAL JOB FUNCTIONS:

1. Ensure that processes within the organization are designed and performed to continually improve the organization’s effectiveness.
2. Ensure that processes with the organization are performed to meet or exceed organizational standards of safety.
3. Facilitates interdepartmental functions and synergizes quality processes.
4. Ensures thorough and accurate compliance with all pertinent federal, local, national, and state regulatory agencies.  Acts as Continuous Quality Improvement Team facilitator. Collaborates with Chief Operating Officer to direct organizational and departmental data monitoring and analysis to ensure compliance.  Collaborates with department directors to initiate and maintain accreditation status with applicable professional trade agencies and regulatory bodies.  Collaborates with, assists, and provides Quality Systems department staff support to all Leadership Team members for preparation for site surveys and audits by external regulatory and trade agencies.
5. Collaborates with the CEO and COO on the organization’s quality improvement process.  Conducts ongoing monitoring of internal and external process occurrences for trends analysis and reporting (i.e. PDSA’s, LEAN & Value Stream Mapping, or R-3).
6. Conducts compliance monitoring of departmental and organizational processes to ensure that quality is consistently maintained.  Reports findings to the CEO and COO, and the appropriate department director.
7. Directs, initiates, and analyzes medical review reporting.
8. Monitors and analyzes information release and activity pertaining to federal, state, and industry standards as it relates to regulatory compliance and organizational operation.
9. Oversees the medical records function by ensuring that release of information requests are responded to in a timely manner while maintaining confidentiality.
10. In collaboration with theVice President of Human Resources and the Director of Education and Development, provides education to staff regarding the quality improvement process.
11. In collaboration with the Vice President of Human Resources, assists with and directs periodic auditing measures to ensure compliance with Occupational Safety Hazard Association (OSHA).
12. Coordinates and monitors the collection and distribution of data required for quality assurance and improvement reporting and independently interprets reported data for accuracy.  Develops trend analysis of organizational performance and reports to the Leadership Team.
13. Presents reports on quality indicators including occurrences and corporate compliance matters to the Board on an annual basis as directed by the CEO.
14. Presents reports and data analyses to the Medical Advisory Committee as requested by the COO, Director of Clinical Services, and Vice President of Medical Services.
15. Collaborates with COO and Director of Clinical Services to maintain all required data collection and analysis systems and tools including iTransplant and a variety of spreadsheets.
16. Collaborates with Director of Clinical Services to ensure interdepartmental synergy, efficiency, and policy compliance.
17. Chairs the Quality Committee.