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TH Medical

RN Clinical Manager Quality CCC Full Time

TH Medical - Joshua Tree, CA

RN Clinical Manager Quality CCC Full Time','!*!RN Clinical Manager Quality CCC Full Time


Reporting to the Director, Clinical Quality Improvement (DCQI), the Manager of Quality and Performance Improvement plans, organizes, and coordinates all aspects of the Continuing Care Center Continuous Quality Improvement program and Quality Assurance Performance Improvement program, ensuring that the Distinct Parts Skilled Nursing Facility (d/p SNF), also known as the Continuing Care Center,  is prepared for regulatory bodies surveys including but not limited to the Centers for Medicaid and Medicare Services (CMS), and California Department of Public Health (CDPH) surveys. Acts as a resource/back-up for the DCQI, when needed, for the acute care facility.

Primary Duties 

• Implements a multidisciplinary approach to continued survey readiness that includes a steering committee and other committees as necessary.  Utilizes tracer methodology as needed.

• Leads the continued survey readiness program to include the development of detailed action plans, setting deadlines, assigning responsibilities and monitoring progress.

• Implements a systematic approach to ensure a high level of awareness of regulatory and accrediting agency requirements throughout the hospital including ramifications of failures in compliance.

• Serves as an expert resource on regulatory/accreditation and licensure standards and expectations for compliance.  Provides consultation to leaders and staff involved with the disease specific certification programs.

• Reviews references materials and communications to stay current with changes in TJC/DHC/CMS guidelines, standards, goals, trends, survey and training methods.  

• Keeps leadership informed about regulatory changes, oversees incorporation into hospital practice and ensures successful implementation of changes.

• Identifies areas of vulnerability and assists leaders in developing corrective action plans.

• Provides education to hospital staff, management and leadership on regulatory items.

• Advises management of the need to add, update and/or modify policies and procedures to meet regulatory requirements. Reviews/revises/proposes policies to ensure compliance with guidelines, regulations, and assists with the creation of new policies.

• Serves as the liaison to regulatory agencies and accreditation bodies. 

• Manages all agency site visits including scheduling, logistics, and communication to those involved.  With unannounced visits, using guest relations skills, determines reason for visit, facilitates retrieval of information and discussion with the most appropriate hospital staff and management.

• Communicates regularly with Tenet Corporate offices to review results of TJC/DHS/CMS surveys, interpret regulations, and understand trends.

• Provides consultation to all departments and the medical staff on the interpretation and application of TJC Accreditation standards, and DHS regulations, such as Title 22.

• Reviews survey results with appropriate management and assists DCQI in development of action plans for compliance.  Through task forces, prepares Joint Commission evidence of standards compliance and measure of success data.

• Assists DCQI in preparation for, responding to, and the management of corporate clinical audits and the Joint Commission PPR.

• Participates in the annual Failure Mode Effects Analysis with the Risk Manager, CNO, and the DCQI.  Follows critical analysis and identification of failure mode (process variation) methodology. 

• Plans, develops, organizes and directs the facility CQI program and the QAPI program.



• Current CA RN license with a minimum of 5 years of experience in acute hospital setting and/or the skilled nursing setting. 

• Bachelor’s degree required, preferably in a health-related field.

• Experience in facilitating regulatory surveys and surveyor visits for Joint Commission, California Department of Public Health, and Centers for Medicare and Medicaid.

• Experience in providing education, team facilitation and coaching.

• Excellent interpersonal, communication skills and presentation skills.

• Proficiency in Microsoft Office','Managers and Directors','CA-Joshua Tree','','Hi-Desert Continuing Care Center','Full-time','Full-time','Days','Days','','','','','','','1805025254','RN Clinical Manager Quality CCC Full Time

18 days 9 hours ago

TH Medical


RN Clinical Manager Quality CCC Full Time TH Medical - Joshua Tree, CA, United States


Location: Joshua Tree, CA

Company Profile:
At Tenet Healthcare, we’ve had a longstanding commitment to serving our patients, our employees, our physicians and our partners. Today, we’re one of the nation’s leading healthcare services companies, with a comprehensive network that extends from coast to coast: