About The Role

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Directs daily operations of assigned functions/areas. Ensures the establishment of sound processes to drive quality care and patient safety, contributing to the attainment of business goals through positive impact on continuous quality improvement outcomes within in assigned areas of responsibility, and in collaboration with the Quality Executive Team. 2. Directs the supervisory and administrative work in directing and coordinating the use of clinical data systems, clinical information systems, platforms that affect utilization, quality of care and services, and are in compliance with Federal, State, and accreditation requirements. 3. Performs value analysis, and unwarranted clinical variation reduction; Develops specific recommendations for review by management. 4. Develops mechanisms to abstract data from all UHealth systems to automate data reporting. 5. Ensures the identification and monitoring of quality indicators and outcomes, collection and analysis of data, achievement of hospital-wide and department specific objectives of the program. 6. Makes recommendations on improvement opportunities with member executives, physicians, management and other leaders on the opportunities for clinical and/or operational effectiveness. 7. Leads, supervises, and/or collaborates with a team of professionals for successful delivery of identified outcomes, inclusive of implementing and managing processes, procedures, and policies that impact clinical quality improvement, accreditation, quality assurance, and regulatory compliance. 8. Ensures critical and valuable information is regularly communicated to leadership and appropriate parties. Develops and continuously monitors an internal reporting structure for assigned quality management matters. 9. Ensures the timely reporting of quality data to appropriate individuals through a systematic and defined multidisciplinary process. Coordinates timely reporting of readiness to leadership via a defined, formal reporting structure. Serves as the principal advisor regarding healthcare quality clinical data systems and clinical data system analytics. 10. Ensures internal control oversight and compliance with laws and regulations, safeguarding of assets, compliance with University policies and procedures, reliability of internal and external reporting, and efficiency and effectiveness of operations. Creates an effective control environment, conducts risk assessment, implements and monitors controls.

This list of duties and responsibilities is not intended to be all-inclusive and may be expanded to include other duties or responsibilities as necessary.

CORE QUALIFICATIONS

Education

Bachelor’s Degree in relevant field

Certification and Licensing

Not Applicable

Required Experience

Minimum 10 years of relevant experience. Clinical experience is required. Experienced with JCAHO and ACHA standards is required.

Knowledge, Skills and Behaviors

Ability to maintain effective interpersonal relationships
Ability to communicate effectively in both oral and written form
Skill in collecting, organizing and analyzing data
Proficiency in computer software (i.e., Microsoft Office)
Knowledge of business and management principles
Ability to effectively plan, delegate and/or supervise the work of others.
Ability to lead, motivate, develop and train others.

DEPARTMENT ADDENDUM

Department Specific Functions

Leads the overall hospital accreditation and regulatory survey readiness programs, and continuous quality assurance in either a primary leadership role, or as a secondary leadership support role. Assumes primary liaison between The Joint Commission (TJC) and UMHC on accreditation-related processes including but not limited to development of facility responses to survey findings, quality-of-care concerns, application submission, on-site visit and post-survey activity proceedings. Presides as Chairperson of the Accreditation Readiness & Response Committee (AR2C) and provides quarterly report to the Patient Safety Events Committee unto the UHealth Board of Directors. Identifies trends, gaps, and proactively develops programs with variety of constituents including hospital leadership, medical and nursing staff to improve organizational performance and compliance with accreditation and regulatory standards that impact quality and safety improvement for UMHC. Supports initiatives in pursuit of elimination of preventable harm by advising high reliability organization techniques. Drives short-term strategies that have long-term operational excellence impact on the achievement and sustainment of accreditation, program certifications and licensure. Translates accreditation, regulatory, and compliance strategies and procedures into actionable plans. Collaborates and advises senior leadership of outcome measures, matrix, performance improvement and effectiveness in alignment with UMHC and UHealth System Mission and Vision. Validates UMHC policies and practices through surveillance reviews for alignment and compliance with accreditation and regulatory standards. Presents survey readiness and compliance reports to UMHC leadership via a defined, formal reporting structure. Educates faculty, administration and staff relative to accreditation survey readiness; performance improvement; and, methods of collecting, analyzing, and reporting of data. Maintains current with accreditation and regulatory changes, evidence-based care practice guidelines and outcomes, and evolving professional and social issues in health care. Optimizes use of resources, equipment and services, ensuring a high level of services. Actively seeks ways to contain costs and reduce unwarranted variations without compromising safety, quality or services delivered. Verifies internal control compliance oversight of assets, policies and procedures, reliability of internal and external reporting, and efficiency and effectiveness of operations. Creates an effective control environment, conducts risk assessment, implements and monitors controls as appropriate. Oversees the department financial management, planning, operations, systems, and controls. Performs supervisory responsibilities in accordance with the University’s policies and applicable law. Responsible for interviewing, hiring, training employees; planning, assigning, and directing work; appraising performance; rewarding and disciplining employees; addressing and resolving problems. Other duties as assigned.

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The University of Miami offers competitive salaries and a comprehensive benefits package including medical, dental, tuition remission and more.

UHealth-University of Miami Health System, South Florida's only university-based health system, provides leading-edge patient care powered by the ground breaking research and medical education at the Miller School of Medicine. As an academic medical center, we are proud to serve South Florida, Latin America and the Caribbean. Our physicians represent more than 100 specialties and sub-specialties, and have more than one million patient encounters each year. Our tradition of excellence has earned worldwide recognition for outstanding teaching, research and patient care. We're the challenge you've been looking for.

The University of Miami is an Equal Opportunity Employer. Applicants and employees are protected from discrimination based on certain categories protected by Federal law.