Reporting to and working under the guidance of the Associate Director for Quality Regulatory Compliance, the Quality Improvement & Regulatory Compliance (QI & RC) Specialist will support the coordination, assessment, monitoring and documentation of a variety of regulatory compliance activities to ensure high quality and safe care is delivered to our patients in accordance with meeting or exceeding pertinent regulatory requirements.
The QI & RC Specialist will work collaboratively with various levels of leadership within the Faculty Practice Organization (FPO) as well as managers and staff throughout the organization. The successful candidate will be exposed to a variety of departments throughout the FPO in the promotion of operations, quality improvement and regulatory compliance initiatives. Responsibilities assigned may be related to but not limited to Patient Centered Medical Home (PCMH), The Joint Commission (TJC), American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF), New York State Department of Health (NYS DOH), United States Drug Enforcement Agency (US DEA), Centers for Medicare and Medicaid Services (CMS), Accountable Care Organization (ACO and other accreditation and regulatory agencies.
Maintains ongoing compliance with Joint Commission, state and federal standards; oversight responsibility for all regulatory body surveys, i.e., Joint Commission, State licensing Reviews, CMS Validation Surveys, health department, local regulatory reviews (fire marshal), and any other regulatory activity that may involve the facility. This responsibility includes staying current with Joint Commission, state, and local standards; educating facility staff about standards; and preparing the facility for such accreditation surveys.
Plans and coordinates quality and regulatory compliance activities including but not limited to site visits and mock surveys to assure appropriate, high quality and regulatory compliant healthcare delivery. This includes development and implementation of Quality Assessment/Performance Improvement plans, evaluation of effectiveness of corrective actions for identified problems and continuous quality improvement activities.
Working knowledge of the New York Patient Occurrence Reporting and Tracking System (NYPORTS) regulatory reporting requirements.
Utilize project management tools to promote timely progression and monitoring of project timelines and deliverables; as well as communicating challenges and results to project stakeholders.
Serves as a resource in the delivery of tasks to advance the development and implementation of performance improvement and regulatory compliance programs in accordance with applicable local, state and national standards, guidelines and/or regulations.
Requires a Bachelor???s degree in Nursing or Master???s degree in Public Health, Healthcare Administration or other healthcare related programs.
At least 3 years of healthcare related experience leading quality/performance improvement and Joint Commission/CMS survey preparation and coordination within a hospital, ambulatory care, ambulatory surgery or clinic setting required.
Must possess strong project management, organizational, interpersonal, written and oral skills.
Must be computer and internet literate with knowledge of EMR systems and strong experience in MS Office, Project, Word, Teams, Excel and PowerPoint.
Candidate must be dependable, detail-oriented, effective team player with a strong service-minded work ethic.
Experience interacting with all levels of faculty, management and staff.
Must be able to maintain the highest level of confidentiality and diplomacy at all times.
Excellent customer service skills and operational experience.
Ability to work within tight deadlines, and manage multiple projects effectively.
Must successfully complete training systems.
Clinical degree RN, NP, PA, PharmD or MD/DO preferred.
Certification as a Certified Professional in Healthcare Quality (CPHQ) required or obtained within 1 year of employment
Certified in Healthcare Compliance (CHC) or Lean Six Sigma desirable.
Current, unrestricted registered nurse license to practice in NY state
Equal Opportunity Employer / Disability / Veteran
Columbia University is committed to the hiring of qualified local residents.
Internal Number: 516514
About Columbia University
Columbia University is one of the world's most important centers of research and at the same time a distinctive and distinguished learning environment for undergraduates and graduate students in many scholarly and professional fields. The University recognizes the importance of its location in New York City and seeks to link its research and teaching to the vast resources of a great metropolis. It seeks to attract a diverse and international faculty and student body, to support research and teaching on global issues, and to create academic relationships with many countries and regions. It expects all areas of the university to advance knowledge and learning at the highest level and to convey the products of its efforts to the world.