Responsible for leadership and strategic direction, oversight, and coordination of the department and functions of Quality Management to include Patient Safety, Clinical Outcomes, Accreditation, Service Excellence. Regularly collaborates with Medical Staff, Hospital Leadership, Infection Preventionist, Patient Safety Officer and outside agents to collect and analyze hospital data, implement strategies and manage outcomes to provide cost effective, quality, and safe healthcare delivery. Communicates effectively with all levels of staff, physicians, and external
groups including regulators, payers, and accrediting bodies.

This job description is not intended to be all inclusive; the employee will also perform other reasonably related business/job duties as assigned.

Minimum education
LVN certification required, actively pursuing RN degree

Registered Nurse Licensed in the State of Texas or Master’s degree in a health related field preferred.

Prior experience in case management, clinical documentation improvement, house supervision, infection prevention,quality, or risk management preferred.

Five years hospital or health care related experience required. Three years in progressive management preferred.

Experience in leading hospital or system accreditation activities required.

Current clinical efficacy of one or more of the following: Clinical Nursing, Critical Care, Case Management (Resource Utilization), Surgical Services, Perinatal Services, Infection Prevention, Accreditation and Regulatory Compliance, Core Measures and Public Reporting of Hospital Quality Data.

Must be able to demonstrate skills related to statistical and systems analysis.

Excellent oral, written and communication skills.

Proven communication skills in dealing with multidisciplinary clinical and operations teams including providers.

A positive, customer friendly attitude necessary.

Required Skills
Requires critical thinking skills, decisive judgment and the ability to work with minimal supervision. Must be able to work in a stressful environment and take appropriate action.

Proven communication skills in dealing with multidisciplinary clinical and operations teams including physicians.

Certifications

BCLS preferred
ACLS preferred
Certification in specialty area of practice highly recommended.
CPHQ preferred.

About Ennis Regional Medical Center

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