Job Description:

This role is the local team member who performs the daily activities of clinical compliance at Salem Hospital. This role will report directly to the Sr. Manager of Quality and Clinical Compliance at Salem Hospital and is responsible for the execution of the clinical compliance programs for Salem Hospital.


This role will maintain sound organizational relationships and work well within a matrixed health care organization. This role will support the execution of long and short-term goals for the MGB clinical compliance programs.


Because this is a position in an active change management environment, this team member will need to demonstrate flexibility and open mindedness as the contours of this position will actively evolve over time..


• Support the MGB clinical compliance strategy within Salem Hospital, adhering to MGB standardized processes around quality measurement, strategy, prioritized areas, and performance improvement while also providing critical feedback about issues and needs that are arising within Salem Hospital.


• This role is an implementer of the clinical compliance programs at Salem Hospital.


• Executes compliance activities at Salem Hospital, ensuring adherence to MGB standardized processes around tracer activity, site level preparedness activities, and measuring/monitoring compliance.


• Be the local Salem Hospital staff member for all compliance activities and support the Senior Manager in ensuring the hospital either meets or exceeds all measures.


• At the direction of the Senior Manager for Quality and Clinical Compliance will submit all required documentation and reports to all relevant accrediting and regulatory bodies for Salem Hospital (DPH, DMH, TJC, BORIM, MedSUN)


• Prepares reports and presentations as needed.


• Supports local training and educational programs as needed.


• Understand data provided by the system team and use knowledge of local practices and culture to identify areas of opportunity for improvement as well as communicate to the system areas which are at risk.


• Provides strong bi-directional communication between the system and the site.


• Must be available to work in case of a hospital declared emergency.


• Must be available to assist during regulatory agency reviews.


• Performs other duties as assigned.



Qualifications

• Preferred: Knowledge of principles of quality measurement, governmental and regulatory quality requirements, process improvement. Demonstrated knowledge in executing improvements in clinical care, as well as holding themselves accountable to sustaining improvement over time. Ability to explain these domains to others, who may or may not have expertise within rigorous quality improvement.


• Demonstrated ability to execute a local quality performance and improvement portfolio.


• Support local site visits from TJC, CMS, DPH, DMH and other bodies as needed.


• Other areas of knowledge include medical records systems; management information systems; applicable statutes and regulatory agency requirements; problem assessment and problem-solving techniques; health care law; health care services.


• Excellent and effective communication skills, both verbal and written


• Ability to interact with individuals and groups at any level; good decision-making skills; personnel management skills.


• Excellent organizational skills, ability to work on multiple projects under multiple deadlines; highly energetic, and able to embrace challenges and change.


• Must be a team player and work well with a variety of people in all levels of the organization.


• Uphold Behavioral Standards in day-to-day interactions.


• Minimum of 2 years' experience in quality and clinical compliance within a hospital preferred


• Undergraduate degree required


• Clinical background preferred

EEO Statement

Salem Hospital is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. Apply Now