Manager Quality & Risk Management & Infection Prevention (Salaried/FullTime - RN License Required)

Summary: Functions as the Manager Quality & Risk Management (MQRM) in a team and mission-based setting to provide responsibility for planning, organizing, and directing the overall operations of quality and risk management and infection prevention program and other specific areas as may be assigned of a rural Critical Access Hospital at Northern Cochise Community Hospital (NCCH).

Quality and Risk Management is responsible for the development, coordination, implementation, and monitoring of activities or actions associated with the quality and risk management plans. Develops and implements programs to promote employees’ health and safety on the job and meet regulatory and legal requirements for the maintenance of employee health records.

MQRM is responsible for creating an environment of patient-centered care through evidence-based standards. MQRM is accountable for formulating the departmental budget(s) and maintains efficient and effective departmental operations while meeting required compliance with all state, federal, and local regulation laws, standards, and protocols. MQRM oversees complaint and grievance process regarding clinical care. Also, responsible for state and federal survey readiness.

MQRM assures competency of department(s) assigned personnel for education, skills, and compliance monitoring. MQRM collaborates with other NCCH departments such as Nursing, Employee Health, Rehabilitation Services, Radiology/Imaging, Respiratory Services, Laboratory, Revenue Cycle, Rural/Specialty Clinics and Emergency Preparedness/Safety teams to ensure appropriate patient care, quality metrics, and services are being performed. MQRM drives NCCH's Quality Assurance Performance Improvement program.

The Manager Quality & Risk Management (MQRM) must possess strong leadership qualities that instill trust and accountability for a successful outcome.

Supervision Required: Works under the direct supervision of the Chief Executive Officer (CEO) or designated administrator.

Reasonable Accommodations / Job Performance:

To perform this job successfully, an individual must be able to perform each essential function and the physical demands satisfactorily.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.   This job description outlines those functions, responsibilities, and success factors upon which the incumbent’s performance may be evaluated.

 Education and/or Experience:

Bachelor of Science in Nursing (BSN) from an accredited school of Nursing or Degree in Health Services Administration required, or relevant experience in lieu of Bachelors. Masters of Science Degree in Nursing (MSN) or Health Services Administration preferred.

 3-5 years hospital direct care nursing experience required.

Additional minimum of 2 years’ experience in Quality / Risk Management / Infection Control preferred.

Certificates, Licenses, Registrations:

§  Current Unrestricted Registered Nurse, license in the State of Arizona required.

§  Current Basic Life Support (BLS) Certificate (American Heart Association), required – must maintain current certification and recertify prior to expiration date.

§  Advanced Cardiac Life Support (ACLS) Certification (American Heart Association), required – must maintain current certification and recertify prior to expiration date.

§  Emergency preparedness training preferred to include Intermediate and Advanced Incident Management System. Completion of NIMS Courses 100, 200, 700 required or obtained within 30 days of hire.

§  Certified Professional in Healthcare Quality (CPHQ) preferred within 12 months of date of hire.

§  Certified in Infection Contril (CIC) from Association for Professionals in Infection Control and Epidemiology (APIC) preferred within 18-24 months of date of hire.

This position summary is designed to outline primary duties, qualifications and job scope, but is not intended to limit the incumbent nor Northern Cochise Community Hospital Inc., to only the work identified.