The Senior Director of Quality Management Systems and Regulatory Affairs is responsible for establishing and promoting quality outcome standards towards safety, effectiveness and efficiency enterprise-wide. Provides leadership for advancing, developing, refining and innovating quality and regulatory operations throughout the organization.

The Senior Director of Quality Management Systems & Regulatory Affairs is accountable for developing, leading, and executing large scale quality support projects around day to day organizational performance throughout the Health System, as well as facilitating leadership to achieve necessary regulatory and performance excellence audit processes.

Core Job Responsibilities

Actively engage in the development and implementation of the strategic plan for Quality Management Systems aligned with the overall strategic plan and ensure the integration of service line planning into applicable service lines. Lead program planning, implementation and evaluation efforts for areas of responsibility at a strategic and tactical level.
Collaborate with administrative and clinical colleagues in strategic planning and the development and evaluation of quality outcomes, metric management and survey/ regulatory readiness for all services.
Determine opportunities to improve the value and equity of care and services to patients and families, working collaboratively across organizational lines to facilitate hospital and nursing operations and ensure patient needs are met.
Promote patient improvement outcomes, comfort and wellness. Ensure exceptional patient experience through patient centered initiatives and support of patient advocate processes.
Oversee enterprise-wide compliance with ongoing regulatory and accreditation readiness sustaining subject matter expertise regarding understanding of regulatory requirements, State Mandated Guidelines, and accreditation standards.
Oversee coordination of the efforts for identified committees, departments and clinical service teams in providing feedback and input into response to the DOH, DNV and other accrediting bodies.
Responsible for the coordination and follow through of regulatory surveys conducted by the DOH as well as collaborating for DNV, CARF, COC and other surveys to ensure responses are congruent with practices throughout the system.
Will act as contact and disseminate regulatory changes, notification of new regulations and facilitation of the response needed.
Collaborates with many other departments to ensure compliance with regulatory information.
Ongoing relationships with DOH, DNV, Administration, Medical Staff, Nursing Staff, Program Directors and/or ancillary services through committees and meetings.
Serve as the Administrator-On-Call for the Health System throughout the year as scheduled/assigned.
Make decisions or recommendations related to performance management, hiring, transfers, corrective actions, terminations, etc. In partnership with Human Resources, resolve or ensure the resolution of staff issues and grievances in a fair, timely and consistent manner. Maintain a focus on internal talent management and retention.
Cultivate a culture that promotes and rewards professional growth, interdisciplinary collaboration, constructive communication, flexibility, teamwork, and customer service.
Ensure the availability of appropriately trained staff to deliver a high quality, consistent standard of care and regulated care. Provide opportunities for staff development based on scientific advances, changes in technology, society, or health care delivery systems.
Keep current in best practices through participation in professional associations and learning opportunities. Represent the health system at state, local and national levels.
Advocate MVHS's diversity, inclusion and health equity mission, strategies and practices to support a diverse workplace and patient population. Leverage the effects of diversity to achieve a competitive business advantage
Performs related duties as assigned.

Education/Experience Requirements

REQUIRED:

Bachelor’s degree in Nursing, a health related field, or equivalent experience
8 years of clinical experience. Previous or current experience working in Quality Management/ Utilization Management field.
5 years of management experience with proven ability to lead, create, and sustain teams
Strong knowledge of pathophysiology, treatment of disease and patient management.
Formal training and demonstrated experience in conducting root cause analysis for adverse events.
Demonstrated knowledge of Quality and Performance Improvement methodology, including data collection/analysis.
Excellent verbal and accurate written skills for communication with regulatory agencies, including DNV, DOH, Administration, Medical Staff, Nursing staff and Ancillary Support Services.

PREFERRED:

Master’s degree in Nursing or a health related field

Licensure/Certification Requirements

REQUIRED:

Licensed NYS Registered Nurse.
CPHQ certification.

Disclaimer

Qualified applicants will receive consideration for employment without regard to their age, race, religion, national origin, ethnicity, age, gender (including pregnancy, childbirth, et al), sexual orientation, gender identity or expression, protected veteran status, or disability.
Successful candidates might be required to undergo a background verification with an external vendor.

Job Details

Req Id 93492
Department QUALITY IMPROVEMENT
Shift Days
Shift Hours Worked 8.00
FTE 1
Work Schedule SALARIED MANAGEMENT
Employee Status A1 - Full-Time
Union Non-Union
Pay Range $117K -$175K

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