JOB SUMMARY: Responsible for the coordination of all organization wide mock tracer and other process improvement activities including facilitating, initiating, providing support, and education. Ensures that the organization is in compliance with standards of regulatory and accreditation agencies (i.e. TJC, DNV, CMS, TDSHS, and other hospital licensing) at all times. Prepares, analyzes, and compiles statistics for reports. Assists to facilitate committee meeting as needed; assists with ethics and compliance issues as needed, assists in the workup and investigation of patient's complaints, and performs other duties as assigned.

MINIMUM QUALIFICATIONS:

1.Education/Specialized Training/Licensure:Bachelors Degree, Nursing or other Allied Health preferred. Certified Specialist in Hospital Accreditation preferred.
2.Work Experience (Years and Area): 5 years of experience in Quality Management or Accreditation

3.Management Experience (Years and Area):5 years of project management preferred
4.Equipment Operated:Personal Computers, printers, copiers, fax machines, window-based software programs (excel, power point, word etc.)

SPECIAL REQUIREMENTS:
1.Communication Skills:
Above Average Verbal (Heavy Public Contact)
Writing /Composing (Correspondence/Reports)

2. Other Skills: Analytical, Design, Dictation/Transcription, Mathematics, Medical Terms, Word Processing, P.C., MS Excel, MS Power Point

3. Work Schedule: Weekends, Holidays, Flexible, Travel, Eligible for Telecommute

4.. Other Requirements:May require extended hours in addition to weekends/holidays for special projects.