HOW WE CARE FOR YOU

At St. Lawrence Health, we are dedicated to getting health care right. Our robust benefits and total rewards foster employee wellbeing, professional development and personal growth. We care for your career while caring for the community.

Same Day pay through Daily Pay

Paid vacation & holiday pay

Medical, dental, vision, hearing benefits

SUMMARY

The Manager, Medical Staff Quality and Regulatory Affairs reports directly to the Director of Quality, Patient Safety, and Regulatory Affairs. The role assists the Chief Medical Officer (CMO) by coordinating the quality, performance improvement, and educational activities of the medical staff. This role is responsible for coordinating and facilitating physician peer review in compliance with DNV and other regulatory standards in conjunction with the CMO and Chair of the Professional Practice Committee. The role assists the Director, Quality, Patient Safety, and Regulatory Affairs by coordinating regulatory accreditation and ongoing certification activities.

St. Lawrence Health (SLH) was established in December 2013 with the mission to improve health and to expand access through coordination and integration of services. SLH became an affiliate of Rochester Regional Health (RRH) in January 2021. Working together with our community partners, including local health departments and agencies, we are focused on disease prevention, promoting access to quality healthcare services, and improving the overall quality of life for our communities.

STATUS: Full Time            

LOCATION: St. Lawrence Health

DEPARTMENT: Quality Management

SCHEDULE: 8 hour shifts

        

ATTRIBUTES

Required: Associate's degree in Nursing

Required: Bachelors' degree in Nursing, Health Sciences, Health Study or a related field

Required: 5 years acute care experience, including experience with case review, peer review, or regulatory readiness required.

Registered Nurse license in New York State required.

Demonstrated leadership ability and ability to communicate effectively Familiarity with health care laws, regulations, and standards of qualityAbility to review, summarize, and analyze dataProven ability to work collaboratively with staff at all levelsAbility to work independently and respond to administrative directivesAbility to grow strong rapport with Medical Staff Providers

RESPONSIBILITIES

Assists with obtaining quality metrics and provider performance data.

Responsible for supporting and coordinating the Professional Practice Committee.

Attends the medical staff peer review meetings and works collaboratively with others on follow-up planning processes/activities.

Assists in the identification of the educational needs of the medical staff.

Closely collaborates with Medical Staff leadership, Quality Management, and Risk Management by providing accurate clinical summaries, data trending, reports and analysis relating to risk, compliance, and peer review.

Responds to OPMC requests when received in collaboration with Quality Management and Risk Management

Assures regulatory compliance with DNV and all other regulatory agencies

Maintains knowledge of Evidence-based, CMS and DNV clinical metrics

Maintains current knowledge of all applicable licensing, regulatory, and accreditation standards and provides assistance to management in ensuring compliance.

Supports onsite assessments, identification of corrective and preventive action plans

Offers training programs to create a culture of learning across the system

Coordinates the internal auditing program

Participates in all state, federal, and accreditation surveys and assists with the writing of the resultant plans of correction and ensures they are carried out in collaboration with the Senior Director of Quality and Regulatory Affairs, Quality Manager, and others as needed

EDUCATION:

LICENSES / CERTIFICATIONS: 

PHYSICAL REQUIREMENTS:

S - Sedentary Work - Exerting up to 10 pounds of force occasionally Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.

For disease specific care programs refer to the program specific requirements of the department for further specifications on experience and educational expectations, including continuing education requirements.

Any physical requirements reported by a prospective employee and/or employee’s physician or delegate will be considered for accommodations.

PAY RANGE:

$88,200.00 - $118,500.00

CITY:

Potsdam

POSTAL CODE:

13676

The listed base pay range is a good faith representation of current potential base pay for a successful full time applicant. It may be modified in the future and eligible for additional pay components. Pay is determined by factors including experience, relevant qualifications, specialty, internal equity, location, and contracts.

Rochester Regional Health is an Equal Opportunity/Affirmative Action Employer.
Minority/Female/Disability/Veterans by a prospective employee and/or employee’s Physician or delegate will be considered for accommodations.