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Lincoln Medical and Mental Health Center is one of New York City's premier acute care hospitals. Located in Downtown Bronx, Lincoln is a teaching hospital renowned for its Centers of Excellence, and a recognized industry leader in the implementation of state-of-the art medical technology and best practices. Our team of highly trained and caring medical professionals is dedicated to providing the highest quality health care that is safe, compassionate, culturally competent and patient-centered. Comprehensive services are offered in three major primary care areas: Medicine, Pediatrics, and Women's Health in addition to more than eighty (80) specialty services. At Lincoln, the safety and comfort of our patients is our number one priority.
At NYC Health + Hospitals, our mission is to deliver high quality care health services, without exception. Every employee takes a person-centered approach that exemplifies the ICARE values (Integrity, Compassion, Accountability, Respect, and Excellence) through empathic communication and partnerships between all persons.
Duties & Responsibilities
PURPOSE OF THE POSITION:
Under the supervision and direction of the Directors of the Quality Management/Regulatory Affairs, develops plans, coordinates, and monitors professional and medical aspects related to the delivery of health care services and ensures the maintenance and attainment of quality care. In collaboration with appropriate leadership, maintains regulatory, accreditation, and certification standards for NYC H+ H/Lincoln.
DUTIES AND RESPONSIBILITIES:
-Stay abreast with current regulations, standards guidelines, and best practices related to CMS, TJC accreditation and TJC certification.
-Develop and implement strategies to ensure the organization is prepared for regulatory/ accreditation and certification surveys and inspections.
-Serve as a liaison with department leaders, responding to inquiries and facilitating the survey process.
-Analyze survey findings, develop corrective action plans, and implement necessary changes to maintain compliance
-Designs and/or reviews performance audits and makes recommendations to improve effectiveness and assess quality standards of health care delivery.
-Coordinate with staff to conduct tracers, identify potential areas of non-compliance, and implement corrective actions.
-Monitors and coordinates the review processes of assigned healthcare programs to determine if programs are meeting the healthcare needs, objectives, and goals established by the Department.
-Assists in the effective administration and completion of the Clinical Chart Review activities, via supervision of the daily concurrent and retrospective reviews conducted by the QM Chart Reviewers. The goals of the daily concurrent and/or retrospective chart reviews include the identification of documentation gaps, and collaboration with the clinical team for timely feedback and timely resolution.
-Chart Review: Able to do clinical Review of patient charts and medical records for accuracy, completeness, and compliance with regulatory standards. Identify and address any deficiencies or areas of concern in documentation and record-keeping, and educates frontline staff on the deficiencies. Implement quality assurance measures to improve chart documentation and maintain high standards
-Advises Director and/or other appropriate leadership on policy and procedural changes, utilization, and
development of staff, implementation of productivity goals, and makes recommendations for improvements in the design of assigned health care programs.
-Performs other duties as assigned by the Director of Regulatory Affairs/Quality Management.
Oversight and Mentorship
-Supervise and mentor staff members, providing guidance, training, and support to ensure they are performing their duties effectively.
-Supervises staff assigned to departmental activities or units and provides professional and administrative direction. Coordinates functional activities and maintains liaison with internal and external sources.
-Conduct performance evaluations and provide feedback to staff to promote professional development and growth.
-Ensure staff compliance with policies, procedures, and regulatory requirements
Minimum Qualifications
1. Master's degree from an accredited college or university in Hospital, Health, Public or Business Administration, Healthcare Management, Public Health or a related discipline; and four (4) years of full-time, paid progressively responsible experience in hospital administration with an emphasis on the development and evaluation of health care delivery services; or
2. Bachelor's degree from an accredited college or university in disciplines, as listed in #1 above; and five (5) years of full-time, paid experience, as described in #1 above.
Department Preferences

• Knowledge of Electronic Medical Records (EPIC)
• Knowledge of Regulatory Agency Processes (Joint Commission)
• Foreign Medical Graduates encouraged to apply (RN, PA, NP's)

Benefits
NYC Health and Hospitals offers a competitive benefits package that includes:

• Comprehensive Health Benefits for employees hired to work 20+ hrs. per week
• Retirement Savings and Pension Plans
• Paid Holidays and Vacation in accordance with employees' Collectively bargained contracts
• Loan Forgiveness Programs for eligible employees
• College tuition discounts and professional development opportunities
• College Savings Program
• Union Benefits for eligible titles
• Multiple employee discounts programs
• Commuter Benefits Programs

If you wish to apply for this position, please apply online by clicking the "Apply for Job" button.