Corporate Project Manager, Quality and Professional Governance

The Corporate Project Manager, Quality and Professional Governance supports the Corporate Director of Healthcare Quality and Safety to ensure Shriners Children's resources, policies, processes, and documentation align with Joint Commission (JC) and National Committee for Quality Assurance (NCQA) standards and requirements for professional practice quality and professional governance. Serves as the system administrator and subject matter expert for the SHC Credentialing statistical database (MD-Stat) responsible for the integrity, security, and functional optimization of the database. Serves as a resource to SC Medical Staff Office, Performance Improvement, Credentialing Verification Office (CVO) Leadership and SC Leadership to ensure regulatory compliance with JC, CMS, NCQA, and SHC Hospital Regulations and Procedural Rules (HRPR) and Medical Staff Bylaws (MSB). Collaborate with HQ Medical Group, quality and accreditation, legal, and compliance, to facilitate a timely implementation of operational objectives. Demonstrates a strong commitment to stakeholder relationships by facilitating effective communication in a timely manner. Performs duties and responsibilities in a manner consistent with Shriners Hospitals for Children's mission and vision. Key Responsibilities: - Collaborate with others in the planning, development, and implementation of regulatory standards and process changes applicable to licensed independent practitioners, related to quality functions. - Maintain current knowledge of hospital accreditation standards, state and federal regulations, and NCQA standards. - Provide guidance and oversight to Medical Staff Office ensuring maintenance of Medical Staff Bylaws, standard privileges, and other documents in accordance with SHC MS Bylaws, HRPR, JC standards, and state laws. - System Lead to the HDQ-Amendment Team providing collaborative action items for the Hospital Regulations and Procedural Rules, and concurrent Medical Staff Bylaws, to the CMO, ACMO, HDQ Quality & Accreditation Team, and Legal Department. - Develop recommendations for SHC HRPR, MS Bylaws, to support and direct organizational practices and ensure ongoing compliance. - At the direction of the Chief Medical Officer, with the Physician Executive Team, coordinate activities on consideration of waivers for international physicians who have not obtained or maintained board certification in compliance with HRPR. - Collaborate with onboarding orientation of SHC Medical Staff Coordinators and Credentialing Specialists as it relates to SHC HRPR and MS Bylaws, including ongoing and focused professional practice evaluation requirements. - Collaborate with Director of Healthcare Quality and Safety, Chief Quality Officer, and SC Medical Group ensuring quality indicators are systematically gathered, analyzed, and standardized across different specialties. - Responsible for specialized internal database (MD-Stat) used for professional practice evaluation data collection, management, and statistical analysis. - Monitor MD-Stat application, including site support of quality metric completion as related to OPPE/FPPE to meet JC and NCQA regulatory requirements. - Perform regular MD-Stat database audits to monitor compliance with requirements in collaboration with SHC Medical Staff Coordinators and Performance Improvement Directors. - Subject matter expert, as well as System Administrator, for MD-Stat and Virtual Committee, developing training and educational materials. - Assist to facilitate a timely implementation of operational objectives and serves as a key stakeholder in the development, execution, and maintenance of enterprise practitioner statistical database. - Develop and maintain systemwide policies and procedures. - Provide planning, implementation, and evaluation for special projects in support of the Chief Quality Officer, Chief Medical Officer, and the Shriners Children's Medical Group - Provides guidance and oversight of Medical Staff Coordinators at Shriners Children's Canada and Mexico as related to credentialing and privileging ensuring compliance with organizational policies, regulatory agencies, and data integrity in MD-Staff credentialing database. - Research and analyze issues, and implement improvements, which support desired outcomes. - Develop, implement, and maintain pertinent Medical Group policy and procedures as they relate to HRPR, MS Bylaws, and JC Standards. - System Administrator, in collaboration with CVO Director, for pertinent enterprise-wide Medical Services Professional Collaborative SharePoint site. - Demonstrate ability to participate in and build effective work teams and promote team-based projects, such as a Joint OPPE/FPPE Steering Committee comprised of cross-functional team to design and audit process effectiveness, to standardize specialty-specific metrics, performance thresholds. - Review OPPE/FPPE systemwide policy annually ensuring compliance with accrediting bodies and Medical Group and Healthcare Quality initiatives. Required Qualifications: - 5 years of experience in a health care setting, with medical staff services, and strong working knowledge of CMS Conditions of Participation, Joint Commission standards, and National Committee for Quality Assurance (NCQA) standards - Knowledge of federal and state regulations and requirements regarding credentialing and related healthcare requirements - Demonstrated database management skills including querying, reporting, database management and document generation - MS Office proficiency - High School Diploma/GED Preferred Qualifications: - Experience with statistical database software suite including MD-Stat, Virtual Committee - Associate's degree (A.A.) in relevant healthcare field - Bachelor's degree (B.S., B.A., etc.) in relevant healthcare field - Certification from National Association of Medical Staff Services as Certified Professional in Medical Services Management Compensation is determined based on years of relevant experience and departmental equity.