Coordinates organization wide efforts to maintain performance that meets or exceeds accreditation standards as set by the Joint Commission (TJC) and the Centers for Medicare and Medicaid Services (CMS), along with Florida State Regulations through the Agency for Healthcare Administration (AHCA). Conducts mock surveys to determine compliance status of hospital sections/departments with TJC, CMS and AHCA standards. Provides orientation, education, and training as necessary to team members. Serves as a resource for all team members relative to accreditation and certification standards. Acts as a hospital liaison with TJC for all TJC related activities. Responsible for performing job duties in accordance with the mission, vision, and values of Tampa General Hospital and the principles of Quality Improvement.

Essential Functions:

• Demonstrates current knowledge and level of expertise required to provide interpret regulatory, accreditation and disease-specific certification standards and perform medical review audits. This includes coordination of all information systems and projects, financials and budget, capital, metrics/analytics and contracts.
• Demonstrate knowledge of Risk Management policies and procedures as well as regulatory requirements in the development and support of TMH programs and processes.
• Ensures a plan is developed and followed to maintain, test, and calibrate departmental equipment including bio- medical devices.
• Coordinates trials for new products/equipment as required.
• Uses a systematic approach to problem solving considering alternate actions when necessary and coordinates problem-solving activities.
• Utilizes priority and time management skills, calendars, and schedules
• Demonstrates the ability to analyze, propose, and coordinate auditing and reporting and disseminate results as needed.
• Promotes new and innovative solutions to current and future challenges through the development of new programs and modification and enhancement of current programs.
• Implements measurement indices which track and monitor operational results.
• Demonstrates understanding of quality improvement processes and utilizes processes to improve operational performance of department/division.
• Provides statistical and financial reports based on systems analysis and incidents to report trends and issues.
• Recommends appropriate solutions.
• Identifies and utilizes appropriate industry benchmark and best practice data sources for data analysis and opportunity identification.
• Ensures internal and external regulatory reporting requirements are met
• Develops, reviews, and updates the department’s plans and operations to ensure the department is prepared for regulatory review and on-site surveys.
• Based on assigned department, may be required to demonstrate the ability to model contracts and other purchasing agreements to determine potential and realized benefit.
• Based on assigned department, may serve as liaison with purchasing for contract review and negotiations.
• In conjunction with Director/VP and manager(s), develops and monitors implementation of departmental annual operating budget, forecasts material, equipment, and personnel needs, and manages the service areas within the prescribed budgetary limits.
• Verifies accuracy of billing submitted to department prior to release for payment. In conjunction with the Director/VP and manager(s) develops the department’s capital budget.
• Based on assigned department, may maintain budget and or other financial/statistical parameters for departmental operations.
• Promotes cost effective operations and utilizes resources effectively and efficiently works with Finance and customer departments to resolve issues related to budget and resource usage.
• Assumes responsibility for tracking fiscal expenditures and revenues.
• Verifies accuracy of billing submitted to the department. Stays informed of issues related to vendor operations by developing and managing relationships with internal and external suppliers of goods and services to the department.
• Adheres to code of conduct policy as it relates to TGH vendor policy.
• Demonstrates current knowledge and expertise required to perform non-routine, complex financial analysis; plan projects; conduct program evaluation studies; perform computer-based modeling projects; develop and implement decision support system strategies.
• Demonstrates the ability to analyze the cause of inaccurate information or financial variances to determine impact;
• Design and implement short and long-term solutions.
• Identifies and plans for developmental needs of existing staff.
• Organizes and/or participates in training for non-department staff as required.
• Required to ensure a work schedule is prepared, communicated, and maintained for all staff supervised.
• Creates and communicates schedules, work plans, standards, and objectives to direct reports and ensures indirect reports receive proper instruction on responsibilities.
• Mentors, coaches, and counsels staff when situations occur.
• Conducts timely performance appraisals.
• Ensures a process is in place to provide up to date information for the orientation, education, and training of departmental employees.
• Effectively trains managers and staff on new and current regulatory and accreditation processes and procedures

• Bachelor's Degree in Nursing.
• 3 to 5 years’ experience in a hospital setting with demonstrated experience with The Joint Commission (TJC) and other regulatory agencies or certification survey processes required.
• 2 years’ experience in quality or regulatory compliance required.
• Experience with related tools including computer programs such as Word & Excel required. FL RN license required or appropriate compact licensure.
• Must obtain Joint Commission Professional Certification (CJCP) within one year of employment.