Directly responsible for the preparation, coordination, and maintenance of survey readiness and regulatory compliance. Position requires strong knowledge of healthcare clinical fundamentals and performance improvement standards.

Works independently and directly with Administrative Leadership, Department Directors and the Medical Staff to coordinate quality improvement programs. Works directly with all regulatory agencies to facilitate on site surveys, both planned and unannounced.

Must facilitate the collection, compilation, display, and analysis of data to prepare summary reports of regulatory activities. Provides coaching, support, and direction to the functional teams as well as to medical staff committees as assigned.

Qualifications

Required Experience:

• Bachelor’s Degree in healthcare or related field
• CPHQ or HACP (or within 2 years of hire)
• Ability to present to and facilitate medical staff meetings
• Five years acute hospital experience with strong clinical background in acute care, preferably in medical/surgical services.
• Strong knowledge of CIHQ Standards, Title 22, and CMS Conditions of Participation standards and other regulatory agency requirements

Preferred:

• Regulatory Survey Experience preferred
• Training and knowledge in the development and implementation of CMS 2567 corrective action plans
• Two years minimum experience in Quality Management

About the Hospital

PIH Health is a nonprofit, regional healthcare network that serves approximately 3 million residents in the Los Angeles County, Orange County and San Gabriel Valley region. The fully integrated network is comprised of PIH Health Downey Hospital, PIH Health Good Samaritan Hospital, PIH Health Whittier Hospital, 37 outpatient medical office buildings, a multispecialty medical (physician) group, home healthcare services and hospice care, as well as heart, cancer, digestive health, orthopedics, women’s health, urgent care and emergency services.

Come to Good Samaritan for a richness of experience beyond the practice of exceptional medicine. With a multi-cultural staff of more than 1,600 employees and 650 physicians, we offer opportunities to work and grow among people from a wide variety of cultures, backgrounds and traditions.