$10,000 Sign on Bonus and Relocation Available.

Facility

Cape Fear Valley Medical Center

Location

Fayetteville, North Carolina

Department

Cancer Center Administration

Job Family

Management

Work Shift

Days (United States of America)

Summary

The Manager of Oncology Accreditation and Quality is responsible for the coordination of all oncology service line accreditation activities including measuring, monitoring, trending, facilitating, initiating, reporting, providing leadership, and education of performance improvement activities. This position serves as a resource to clinical and administrative leaders in the interpretation and application of accreditation standards, facilitating quality improvement teams, ensuring implementation of quality improvement strategies using appropriate quality methodology, tools, and techniques. Position is responsible for the overall components of the Oncology Quality Program.

Major Job Functions

The following is a summary of the major essential functions of this job.  The incumbent may perform other duties, both major and minor, that are not mentioned below.  In addition, specific functions may change from time to time:

• Oversee all accreditation and certification activities for the Oncology Service Line

• Develop action plans to address deficiencies

• Create and manage multiple accreditation and certification project plans

• Assemble accreditation teams and assigns responsibilities; provides guidance and assistance to team members for reporting, as needed

• Responsible for setting up Cancer Committee meetings, distributing meeting agendas and minutes to Cancer Committee members, documenting attendance, and ensuring all information and documentation from each meeting are collected and housed in centralized location

• Manages submission of compliance for each accreditation and certification survey and ensures all deadlines are met

• Coordinates onsite accreditation and certification surveys

• Interfaces and networks with accrediting representatives relating to surveys, plans of corrections, regulatory policies and standards interpretation

• Works with Oncology Leadership to maintain regulatory requirements of TJC, CMS, State, etc.

• Coordinates internal and external inspections and collaborates with Quality and Safety to prepare reports and responses for inspection findings

• Leads strategic internal quality management program for the Oncology Service Line through defined metrics, audits, trending, measurements, outcome analysis, and reporting of results

• Prepares and publishes monthly Oncology Service Line Metrics and Dashboard and submits to CFVH and Oncology Leadership and Cancer Center members

• Prepares quality data reports and presents to CFVH quality boards, Cancer Committee, and others

• Other duties as assigned

Minimum Qualifications

The following qualifications, or equivalents, are the minimum requirements necessary to perform the essential functions of this job:

Education and Formal Training: 

• Currently licensed as a registered nurse in North Carolina

• Bachelor’s Degree from Accredited School of Nursing Required

• 3 years oncology RN experience preferred

• CPHQ certification preferred

Work Experience: 

• 3 years of previous work experience in a healthcare setting required.

• 3 years experience in regulatory compliance and audits required

• 3 years in survey processes and submissions for accrediting bodies preferred

• 3 years experience in the Oncology setting preferred

• Previous leadership experience is preferred

Knowledge, Skills, and Abilities Required: 

• Working knowledge of regulatory and accreditation and state, federal, and professional industry standards pertaining to the healthcare industry

• Excellent verbal and written communication skills

• Ability to interpret and implement requirements of accrediting agencies

• Excellent analytic, problem solving, persuasion, and negotiation skills

• Must be self-motivated, possess independent judgment, able to work independently or collaboratively, and able to handle multiple competing priorities and deadlines

• Ability to work with highly sensitive data in a confidential and professional manner

• Microsoft Office skills

Physical Requirements: 

• Hearing, vision, and verbal communication are required.

• Requires prolonged sitting and manual dexterity to operate keyboard and other office equipment.

Required Licenses and Certifications

Cape Fear Valley Health System is an Equal Opportunity Employer M/F/Disability/Veteran/Sexual Orientation/Gender Identity