Spine Accreditation and Registry Program Manager

Overview

Job Summary 

In collaboration with Spine COE leadership, the accreditation & Registry manager is responsible for all aspects of programmatic management as it relates to accreditation guidelines and participation in the American Spine Registry for the spine service.   The Program Manager, in partnership with respective leadership team, develops and implements the program to drive quality, value, growth and affordability; improve outcomes; enhance local, regional, national reputation; and deliver superior patient/caregiver experience. Collaborates with leaders across the Market footprint from the operating rooms, labs, in-patient units, imaging, ambulatory offices, and any other services or departments that affect the full continuum of care for the designated diagnosis- based populations of patients served by specific service line. 

Essential Functions 

• Manage the development, implementation, and evaluation of the COE’s quality improvement (QI) program that includes collaboration with ancillary services, nursing, and medical staff departments to identify trends, prioritize and recommend improvements, and ensure Joint Commission Accreditation
• Partner with ambulatory and departmental leadership to ensure processes support accurate data capture and collection of patients reported outcomes to adhere with requirements for participation in the American Spine Registry (ASR).
• Monitor for changes and ensures that operations and employees are in compliance with regulatory and/or accreditation agency standards, policies. 
• Develops dashboards, action plans and other tools in order to continuously monitor key performance indicators, including but not limited to: referrals, volume, cost of care, access, quality and safety, appropriateness of care/service etc. 
• Participates with the team to assess, plan, and implement changes as required to achieve goals and meet accreditation standards. 
• Keeps abreast of current TJC standards and other accreditation requirements, and the latest quality techniques in health care.
• Lead, manage and track improvement initiatives and program-related projects/quality improvement initiatives that focus on identified patient safety or quality of care opportunities
• Collaborate with Enterprise, COE and departmental representatives relative to patient reported data and quality metrics.
• Collaborate with Enterprise Center of Excellence/service line leadership to ensure consistency is program development and execution.
• Serve as primary point of contact for the spine quality and registry program for internal and external stakeholders.
• Develop and maintain highly effective professional relationships with referring providers, program leaders, colleagues from other systems and vertical hospital leadership
• Ensure processes are in place to support accurate data capture and submission of patient reported outcomes.
• Serves as the administrative lead and dyad partner to the clinical leader of the Patient Experience and Outcomes subcommittee.
• Organizes and coordinates all assigned functions to provide for a smooth cost-efficient operation. 

Physical Requirements 

Works in an office environment; requires walking, standing and long periods of sitting and computer use; intact sense of sight and hearing required. 

Education, Experience and Certifications 

• Bachelor’s degree required in related field, Master’s degree preferred. 
• Project management experience preferred. 
• 5 years of related experience preferred. 
• Experience with Microsoft Office suite of tools is required.
• Proven track record of achieving goals timely and collaboratively. 
• Demonstrated initiative, ability to work with others, and good professional judgment.
• Ability to work independently and organize time effectively.
• Excellent written and verbal communication