Quality and regulatory manager Resume

EXPERIENCE:

Quality and regulatory manager

Confidential

Responsibilities:

Responsible for Quality, Safety and Risk management for the hospital.
Regulatory readiness training for the hospital staff in preparation for Joint Commission, DPH, CMS surveys.
Facilitate and document tracer survey activities for all hospital units
Initiate and develop performance improvement teams to work on high risk, high priority and/or high - volume initiatives that link directly to the hospital strategic plans.
Active membership on numerous committees including; Sepsis, Ethics, Compliance, Disease Specific Certification teams.
Compile, interpret and report various quality data metrics for monitoring and organizational performance improvement.
Certified through CHA as a High Reliability trainer for Safety Starts with Me.
Developed refresher curriculum for high reliability training to provide to all staff
Root cause and apparent cause analysis for adverse and sentinel events.
Reporting of adverse and sentinel events to appropriate regulatory agencies, facilitation of corrective action plans for quality improvement.
Oversight of core measure abstraction and reporting to CMS and The Joint Commission.
Review of all incident reporting and scoring using HPI methodology.
Work directly with defense counsel on claims and potentially compensable events.
Facilitator for Nursing and Medical Peer Review.
Review and oversight of OPPE and FPPE process metrics.

Quality Consultant

Confidential

Responsibilities:

Chart Review for resolution of complaints and grievances.
NSQIP SCR chart abstraction for surgical quality performance and monitoring
Risk Management including claims analysis and review
Facilitator for Nursing and Medical Peer Review
Facilitated performance improvement projects.
Regulatory oversight - participated in surveys for various regulatory agencies (CMS, Joint Commission, DPH)

CLINICAL COORDINATOR

Confidential

Responsibilities:

NURSING SUPERVISION

Confidential

Responsibilities:

Oversight of hospital operations during off shift hours.
Responsible for assignment of staffing, patient flow, bed assignments, and transfers.

IV THERAPIST

Confidential

Responsibilities:

Responsible for the care of intravenous lines throughout the hospital, including initiating IV access and central line maintenance.
Assisted with education and competency for IV training skill sets for new RN’s.