Posted: 25-Feb-26
Location: ALLIANCE, Nebraska
Type: Full Time
Categories:
Sector:
Required Education:
Internal Number: Req # 3059
General Summary of Responsibilities:
Provides clinical and administrative leadership and direction to the quality division and other assigned departments.
Facilitates development, implementation, delivery and evaluation of services within the assigned areas through collaboration with the clinical/medical staff , nursing leaders, and other managers. Assures achievement of goals and adherence to policies, procedures, and standards set forth by state, federal, and hospital regulatory agencies. Creates an environment of innovation and creativity.
Accountable for establishing operational mechanisms and quality leadership structures which facilitate safe and quality patient care and working environment.
Essential Job Functions:
Communication and Relationship Management
Builds collaborative relationships:
- Communicates organizational vision, mission and values
- Demonstrates effective written, oral communication and presentation skills
- Builds effective physician/provider and administrative leadership teams
Strategic Leadership
Sets the overall direction for Infection Control, Quality and Employee Health Program:
- Encourages a high level of commitment to the purpose and values of the organization
- Participates in the creation of a performance-based culture that maximizes employee potential and fosters high ethical standards in meeting BBGH’s vision, mission and values
- Establishes key performance indicators and benchmarks to measure and monitor progress in achieving quality goals, driving accountability and transparency across the organization
- Explores opportunities for the growth and development of the organization on a continual basis
- Provides strategic direction and leadership in the development, implementation and evaluation of quality initiatives, leveraging data-driven insights and best practices.
- Works directly with nursing leadership to communicate, guide and support patient care through data analysis
- Plans for leadership succession
Professionalism
Acquires and stays current with the professional body of knowledge
- Mentors, advises, coaches and develops all assigned managers.
- Networks with colleagues
Quality Assurance and Improvement:
Oversees and guides the system-wide quality program, including data collection, analysis, policy maintenance, and reporting to key stakeholders, such as Senior Leadership, Medical Staff, and the Board of directors:
- Focuses on improving healthcare value and quality across various dimensions, including clinical outcomes, patient experience, safety, costs, revenue, and employee satisfaction, leveraging performance metrics and continuous feedback mechanisms.
- Co-Manages and supports physician peer review process.
- Oversees the grievance process and works with department managers to resolve complaints
- Leads and supports development and review of policies, procedures and standards of practice that align with federal, state and accreditation agencies
- Maintains role, focus, intensity and persistence, even under adversity
Patient Safety and Risk Management
Designs, coordinates, and maintains patient safety and risk management programs, proactively identifying and mitigating risks to enhance patient safety and minimize adverse events.
- Leads the development and oversight of systems for event reporting, near-miss reporting, and root cause analysis
- Develops and implements a division vision that integrates hospital and program goals, priorities and values
- Ensures timely investigation, analysis, documentation, and follow up of adverse events, sentinel events, and high-risk occurrences
- Promotes and supports a Just Culture framework that supports transparency, accountability and learning
- Delegates and oversees regulatory reporting
Knowledge of the Healthcare Environment
- Demonstrates knowledge of corporate compliance laws and regulations (e.g. HIPAA, billing and coding practices, antitrust, conflict of interest, etc.)
- Demonstrates an understanding of global healthcare issues, trends and perspectives (e.g. population health, insurance costs, malpractice crisis, healthcare workforce shortages, etc.)
- Demonstrates an understanding of the regulatory and administrative environment in which the organization functions (e.g. Stark laws, accreditation, etc.)
Professional Expectations
Functions as the hospital’s Corporate Compliance Officer and Risk Manager
- Maintains responsibility and oversight for the areas of Quality Management, Corporate Compliance, Risk Management, Utilization Management, Infection Control, Accreditation, Behavioral Health, and Occupational Health programs.
- Serves as the chief spokesperson for patient grievance and patient satisfaction processes.
- Coordinates hospital Ethics Committee activities, hospital safety program, and employee safety program.
- Arranges for and provides education to medical and hospital staff regarding policies, standards, regulations, laws, current protocols, and best practice guidelines.
- Collaborates with other executives in the organization in making decisions about health care services, settings, and organizational priorities.
- Directs budget preparation, resolves problems that may arise and presents balanced budget to the CEO.
- Fosters an environment of accountability and relentlessly pursues continuous improvement within the hospital.
- Responsible for the development of leadership within the division
- Serves as an advocate for continuing education, staff development, and organizational development.
Other Job Functions:
Other duties as assigned
Job Qualifications:
Education
Required: Bachelor’s degree in nursing, healthcare administration, or a similar field of study with a strong analytical base, required. Master’s degree in nursing, healthcare administration, or a similar field of study with a strong analytical basis, preferred.
Preferred: Recent experience in quality management and familiarity with the accreditation process. Five years’ experience in acute or managed health care setting, including one year in infection control, epidemiology, or related field;
Conditional: Completion of a Master’s Degree in Nursing or a related field within five years of hire date in this position with demonstrated yearly progress toward completion of the Master’s Degree.
Experience:
Required: Five years’ leadership experience in acute, hospital, or managed health care setting, including experience in quality, infection control, epidemiology, or related field
Preferred: Recent experience in quality management, corporate compliance, utilization management, discharge planning, or social work and familiarity with The DNV accreditation process
License/Certifications
Required: Valid Driver's License
Preferred: Certification in infection control, and related areas of responsibility
Conditional: CPHQ Certification within 5 years (hospital to support education)
