When submitting a resume/CV by email, you must include the job title and posting number in the subject line of your email. An application or resume/CV must be filed for each position which interests you.
To receive Veteran Preference, appropriate discharge papers must be attached to the online application or must be included with your emailed resume/CV. Please refer to Veteran Preference document requirements listed on the bottom of this posting.
Under the direction of the Chief Quality Officer, directs the strategic management and planning for Joint Commission Accreditation and accreditation related activities for all clinical services throughout the health system, including hospitals, clinics, behavioral health centers and ambulatory surgery centers. Sets guidelines to meet requirements for Joint Commission Accreditation leading to successful accreditation for all entities within the health system. Develops and maintains a comprehensive accreditation project plan adhering to standards, prioritized interventions and on-going monitoring for compliance as established by Joint Commission for all accreditation requirements. Develops and manages a plan to assure compliance with Centers for Medicare and Medicaid Services (CMS) Conditions of Participation. Coordinates efforts to earn outstanding clinical performance and a positive customer experience as required for accreditation. Coordinates efforts to assure regulatory compliance with standards established by our managed care partners.
General Administrative Responsibilities
Review applicable Collective Bargaining Agreements and consult with Labor Relations to generate management proposals
Participate in collective bargaining negotiations, caucus discussions and working meetings
Document, recommend and effectuate discipline at all levels
Work closely with labor relations and/or labor counsel to effectuate and enforce applicable Collective Bargaining Agreements
Initiate, authorize and complete disciplinary action pursuant to CCH system rules, policies, procedures and provision of applicable collective bargaining agreements
Direct and effectuate CCH management policies and practices
Access and proficiently navigate CCH records system to obtain and review information necessary to execute provisions of applicable collective bargaining agreements
Contribute to the management of CCH staff and CCH' systemic development and success
Discuss and develop CCH system policy and procedure
Consistently use independent judgment to identify operational staffing issues and needs and perform the following functions as necessary; hire, transfer, suspend, layoff, recall, promote, discharge, assign, direct or discipline employees pursuant to applicable Collective Bargaining Agreements
Work with Labor Relations to discern past practice when necessary
Establishes guidelines to meet Joint Commission accreditation requirements
Develops and leads a regulatory survey readiness program in support of the organization's mission, values and business objectives
Develops and maintains a comprehensive project plan linked to standards with on-going monitoring and reporting to senior management
Serves as the System's resource in questions related to accreditation and to CMS standards
Works with CCHHS senior management and clinical staff in leading and managing all aspects of the accreditation process and standard adherence
Coordinates activities with subject matter experts and unit business owners
Conducts training and coaching to support understanding of accreditation standards and requirements
Develops and maintains plans to assure compliance with regulatory requirements of managed care plans
Develops and manages audit activities to ensure compliance with accreditation standards and develops and maintains a dashboard to demonstrate ongoing compliance
Facilitates communication of information among governance committees and serves as liaison on accreditation issues and changing standards
Maintains accreditation and audit document library
Maintains and updates policy library
Performs other duties as they might be assigned
Reports to the Chief Quality Officer
Bachelor's degree from a four-year accredited university
Successful completion of the accreditation process resulting in a fully accredited designation
Five (5) years of experience in management or leadership role within a large hospital or healthcare system
Seven (7) years of experience with accreditation and regulatory survey process, development and follow-up of corrective plans
Proficiency using Microsoft Office (Outlook, Excel, Word, and PowerPoint)
Five (5) years of experience in developing and implementing an accreditation plan in healthcare environment
Master's or similar degrees in healthcare administration, such as MBA, MHA, MS, MPH, or MPA
Additional certification in healthcare quality management from a recognized organization
Expert knowledge of regulatory environment including Joint Commission, CMS, National Committee for Quality Assurance (NCQA)
Knowledge, Skills, Abilities and Other Characteristics
Excellent verbal and written communication skills necessary to communicate with all levels of staff and a patient population composed of diverse cultures and age groups
Excellent program development, management and leadership skills
Strong customer service and empathy skills
Must be able to work flexible hours
Must be able to travel throughout Cook County
Performs other duties as assigned
Physical and Environmental Demands
This position is functioning within a healthcare environment. The incumbent is responsible for adherence to all hospital and department specific safety requirements. This includes but is not limited to the following policies and procedures: complying with Personal Protective Equipment requirements, hand washing and sanitizing practices, complying with department specific engineering and work practice controls and any other work area safety precautions as specified by hospital wide policy and departmental procedures.
The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of the personnel so classified.
For purposes of the American with Disabilities Act, "Typical Duties" are essential job functions.
When applying for employment with Cook County Health, preference is given to honorably discharged Veterans who have served in the Armed Forces of the United States for not less than 6 months of continuous service
To take advantage of this preference a Veteran must:
Meet the minimum qualifications for the position.
Identify self as a Veteran on the employment application by answering yes to the question by answering yes to the question, "Are you a Military Veteran?"
Attach a copy of their DD 214, DD 215 or NGB 22 (Notice of Separation at time of application filing. Please note: If you have multiple DD214s, 215s, or NGB 22S, Please submit the one with the latest date. Coast Guard must submit a certified copy of the military separation from either the Department of Transportation (Before 9/11) or the Department of Homeland Security (After 9/11). Discharge papers must list and Honorable Discharge Status. Discharge papers not listing an Honorable Discharge Status are not acceptable
A copy of a valid State ID Card or Driver's License which identifies the holder of the ID as a Veteran, may also be attached to the application at time of filing.
If items are not attached, you will not be eligible for Veteran Preference
VETERANS MUST PROVIDE ORIGINAL APPLICABLE DISCHARGE PAPERS OR APPLICABLE STATE ID CARD OR DRIVER'S LICENSE AT TIME OF INTERVIEW.
MUST MEET ALL REQUIRED QUALIFICATIONS AT TIME OF APPLICATION FILING.
"Degrees awarded outside of the United States with the exception of those awarded in one of the United States' territories and Canada muse be credentialed by an approved U.S. credential evaluation service belongings to the National Association of Credential Evaluation Services (NACES) or the Association of International Credential Evaluators (AICE). Original credentialing documents must be presented at time of interview".
*Please note all offers of Employment are contingent upon the following conditions: satisfactory professional & employment references, healthcare and criminal background checks, appropriate licensure/certifications and the successful completion of a physical and pre-employment drug screen.
*CCH is strictlyprohibitedfromconditioning,basing or knowinglyprejudicing or affecting any term or aspect of Countyemployment or hiringupon or because of any politicalreason or factor.
COOK COUNTY HEALTH IS AN EQUAL OPPORTUNITY EMPLOYER.
ABOUT COOK COUNTY HEALTH (CCH)
The Cook County Health’s mission is to deliver integrated health services with dignity and respect regardless of a patient’s ability to pay; foster partnerships with other health providers and communities to enhance the health of the public; and advocate for policies that promote the physical, mental and social wellbeing of the people of Cook County.
CCH is comprised of two hospitals, John H. Stroger, Jr. Hospital and Provident Hospital, a robust network of more than a dozen community health centers, the Ruth M. Rothstein CORE Center, the Community Triage Center, the Cook County Department of Public Health, Cermak Health Services, which provides health care to individuals at the Cook County Jail and the Juvenile Temporary Detention Center, and CountyCare, a Medicaid managed care health plan.
The system cares for more than 300,000 patients each year and its physicians are experts in their fields, committed to providing their patients with comprehensive, compassionate and cutting-edge care. Today, CCH is transforming the provision of health care in Cook County by promoting community-based primary and preventive care, growing an innovative, ...collaborative health plan and enhancing the patient experience.
COOK COUNTY HEALTH IS AN EQUAL OPPORTUNITY EMPLOYER