QA/Clinical Effectiveness Director - FT, Days
Catholic Health Initiatives - Roseburg, OR

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Pay Scale:
Contact Human Resources at 541-677-2475 for salary information.

Days, Monday - Friday

Job Summary:
Under the direction of the Chief Medical Officer primarily and the Chief Nursing Officer secondarily the Clinical Effectiveness Director acts as a visionary leader and internal consultant for total quality management, utilization management, case management, social services, and Infection Control/Employee Health. The director plans, organizes, directs, and communicates quality activities for Mercy Medical Center, including medical staff, nursing and ancillary services. All activities will be conducted in a manner that is consistent with the Philosophy and Mission of Mercy Medical Center.

Essential Duties:
Develops annual department goals, prepares annual department budget and works within the budgetary guidelines of the organization.

Responsible for the selection, training/orientation, competency and ongoing performance appraisals of staff. Provides coaching and development opportunities for staff to reach their potential. Counsels and provides progressive discipline when needed.

Develops and supervises all aspects of the Quality Improvement Program which meets Quality Improvement Committee recommendations and applicable accrediting organization guidelines. These guidelines may include but are not limited to those set by The Joint Commission or other similar accrediting body, the Centers for Medicare and Medicaid Services, CFR’s and the State of Oregon. Reviews and updates program annually and as necessary.

Oversees and co-ordinates Lean process review and implementation, six-sigma principles, and other indicated quality and waste minimization tools to achieve hospital strategic goals and functions.

Reviews, analyzes and monitors data, prepares reports on problems and trending, noting corrective action and improvement. Proactive in identification and resolution of improvement opportunities for Quality & Care Management.

Ensures appropriate dissemination of clinical staff peer review findings to the responsible governing bodies within the institution including the Medical Executive Committee, Board of Directors, and the credentialing process; Safeguards and supervises the maintenance of physician peer review files in accordance with applicable laws and regulations.

Coordinates, develops, retrieves and analyzes patient care outcomes and metrics by concurrent and retrospective processes and outcome monitoring for Medical Staff, Nursing and Ancillary services.

Maintain oversight and direction of the Core Measures and Evidence Based Practices. Remain current and advise the Chief Medical Officer and Chief Nursing Officer on all CMS Core Measure and Evidence Based Practice requirements.

Serves as a resource person for the personnel and Medical Staff in regards to retrieval and analysis of data requests for information or studies utilizing computer statistics.

Acts as a resource person to Nursing Services and Ancillary services for the development of patient interviews and monitoring activities.

Substantially comply with state, federal, and accrediting body standards.

Assumes primary responsibility for The Joint Commission certification or other regulatory and certifying body accreditation; remains current on all requirements of corporate, state, and The Joint Committee or other accrediting body organization requirements by attending relevant workshops/seminars and reviewing appropriate literature. Responsible for provision of necessary education to department leaders regarding all applicable regulatory requirements.

Collaborates with COO/CNO on development of corrective action plans for any regulatory compliance concerns.

Oversees Medical Staff meetings including notifications, agenda, minutes, location arrangements and ensures appropriate dissemination of information to other needed committees.

Collaborates with Risk Management as necessary to monitor, prevent, mitigate risk producing events and respond to unanticipated events and disclosures of unanticipated outcomes in a coordinated manner with involved parties.

Oversee the functioning of the Utilization Management/Case Management, Discharge Services, and Social Services. Oversees the Infection Control and Employee Health Programs. Responsible for policy development, administrative direction, and efficiency of these departments.

Work with internal Case Managers and external stakeholders to ensure appropriate and indicated hospital utilization, medical necessity, status determination, care coordination, care progression, and care transitions processes.

Collaborates with Coding and Documentation Initiative specialists (CDI) to maximize efficiencies for the facility.

Maintains discretion in inter-department communications and is able to retain confidential information in its proper areas.


Bachelors Degree or higher from an accredited institution


Must possess a RN degree.

Candidates possessing a Master’s degree in a health management field will be given preference.

A minimum of five years demonstrated relevant acute care clinical experience required.

A minimum of five years of director level experience with direct staff reports is required.

Working knowledge of Case Management/Utilization Management and Care transitions experience strongly preferred.

Experience in Medical Staff and Nursing Quality Management and efficiency programs including Six-Sigma, LEAN, or other quality efficiency programs is required.

Registered Nurse as licensed by state.

CPHQ certification will be given preference.

Additional Responsibilities:
Demonstrates a commitment to service, organization values and professionalism through appropriate conduct and demeanor at all times.

Adheres to and exhibits our core values:
Having a profound spirit of awe and respect for all creation, shaping relationships to self, to one another and to God and acknowledging that we hold in trust all that has been given to us.

Moral wholeness, soundness, uprightness, honesty and sincerity as a basis of trustworthiness.

Feeling with others, being one with others in their sorrows and joys, rooted in the sense of solidarity as members of the human community.

Outstanding achievement, merit, virtue; continually surpassing standards to achieve/maintain quality.

Maintains confidentiality and protects sensitive data at all times.

Adheres to organizational and department specific safety standards and guidelines.

Works collaboratively and supports efforts of team members.

Demonstrates exceptional customer service and interacts effectively with physicians, patients, residents, visitors, staff and the broader health care community.

Catholic Health Initiatives and its organizations are Equal Opportunity Employers



Primary Location

OR-Roseburg-Mercy Medical Center



Scheduled Hours per 2-week Pay Period


Weekends Required



Full Time

Catholic Health Initiatives - 16 months ago - save job - block
About this company
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For Catholic Health Initiatives (CHI), returning sick people to good health is more than a business -- it's a mission. Formed in 1996...