Medical Staff Quality and Regulatory Affairs Manager
Rochester Regional Health

Description

HOW WE CARE FOR YOU

At St. Lawrence Health, we are dedicated to getting health care right. Our robust benefits and total rewards foster employee wellbeing, professional development and personal growth. We care for your career while caring for the community.

• Same Day pay through Daily Pay
  
• Paid vacation & holiday pay
  
• Medical, dental, vision, hearing benefits
  

SUMMARY

The Manager, Medical Staff Quality and Regulatory Affairs reports directly to the Director of Quality, Patient Safety, and Regulatory Affairs. The role assists the Chief Medical Officer (CMO) by coordinating the quality, performance improvement, and educational activities of the medical staff. This role is responsible for coordinating and facilitating physician peer review in compliance with DNV and other regulatory standards in conjunction with the CMO and Chair of the Professional Practice Committee. The role assists the Director, Quality, Patient Safety, and Regulatory Affairs by coordinating regulatory accreditation and ongoing certification activities.

St. Lawrence Health (SLH) was established in December 2013 with the mission to improve health and to expand access through coordination and integration of services. SLH became an affiliate of Rochester Regional Health (RRH) in January 2021. Working together with our community partners, including local health departments and agencies, we are focused on disease prevention, promoting access to quality healthcare services, and improving the overall quality of life for our communities.

STATUS: Full Time

LOCATION: St. Lawrence Health

DEPARTMENT: Quality Management

SCHEDULE: 8 hour shifts

ATTRIBUTES

• Required: Associate's degree in Nursing
  
• Required: Bachelors' degree in Nursing, Health Sciences, Health Study or a related field
  
• Required: 5 years acute care experience, including experience with case review, peer review, or regulatory readiness required.
  
• Registered Nurse license in New York State required.
  
• Demonstrated leadership ability and ability to communicate effectively
• Familiarity with health care laws, regulations, and standards of quality
• Ability to review, summarize, and analyze data
• Proven ability to work collaboratively with staff at all levels
• Ability to work independently and respond to administrative directives
• Ability to grow strong rapport with Medical Staff Providers

RESPONSIBILITIES

• Assists with obtaining quality metrics and provider performance data.
  
• Responsible for supporting and coordinating the Professional Practice Committee.
  
• Attends the medical staff peer review meetings and works collaboratively with others on follow-up planning processes/activities.
  
• Assists in the identification of the educational needs of the medical staff.
  
• Closely collaborates with Medical Staff leadership, Quality Management, and Risk Management by providing accurate clinical summaries, data trending, reports and analysis relating to risk, compliance, and peer review.
  
• Responds to OPMC requests when received in collaboration with Quality Management and Risk Management
  
• Assures regulatory compliance with DNV and all other regulatory agencies
  
• Maintains knowledge of Evidence-based, CMS and DNV clinical metrics
  
• Maintains current knowledge of all applicable licensing, regulatory, and accreditation standards and provides assistance to management in ensuring compliance.
  
• Supports onsite assessments, identification of corrective and preventive action plans
  
• Offers training programs to create a culture of learning across the system
  
• Coordinates the internal auditing program
  
• Participates in all state, federal, and accreditation surveys and assists with the writing of the resultant plans of correction and ensures they are carried out in collaboration with the Senior Director of Quality and Regulatory Affairs, Quality Manager, and others as needed
  

PHYSICAL REQUIREMENTS: S - Sedentary Work - Exerting up to 10 pounds of force occasionally Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.

PAY RANGE: $88,200.00 - $118,500.00

The listed base pay range is a good faith representation of current potential base pay for successful applicants. It may be modified in the future. Pay is determined by factors including experience, relevant qualifications, specialty, internal equity, location, and contracts.

Rochester Regional Health is an Equal Opportunity / Affirmative Action Employer. Minority/Female/Disability/Veteran

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