The Credentialing & Quality Specialist works closely with the Director of Quality and facility leadership to implement processes that support Tappahannock Hospital’s Quality Management System (QMS). Works with VCU Health’s Centralized Verification Office (CVO) and manage on site credentialing and privileging process. Assists Quality Director with tracking and supporting medical staff quality reviews. Responsibilities include providing hospital wide support for the policy and procedure system, accreditation, compliance, and readiness; assisting Quality Director in developing processes, plans, and tools in order to maintain ISO requirements for education and document control; support quality improvement committees by taking minutes and scheduling meetings; serving as the business application expert and technical support for all team members hospital- wide; coordinate the revision of policies and procedures with department leaders when necessary; auditing VCUHTH’s policies and procedures and informing department leaders of revision needs as appropriate.

Licensure, Certification, or Registration Requirements for Hire:
Certified Professional in Healthcare Quality preferred

Licensure, Certification, or Registration Requirements for continued employment: N/A

Experience REQUIRED:

Proficient in Windows-based operating software and systems that include MS Word, MS Excel, MS Access and MS PowerPoint.

Effective interpersonal, verbal and written communication skills, with an ability to express and document situations and processes.

Experience PREFERRED:

3-5 years of healthcare experience required; experience in healthcare quality preferred

Experience in business/software application management such as data analysis and reporting

Project management experience

Education/training REQUIRED:
Associates Degree in Nursing, Healthcare Administration, Business Administration or related clinical or academic field.

Education/training PREFERRED:
Bachelor’s degree

Master’s degree in healthcare related field (e.g., MHA, MSHA, MSN, MPH)

Supplemental course work in quality improvement, such as quality methodologies/tools, data analysis, patient safety, Lean six sigma, project management.

Independent action(s) required:
Think independently, organize, plan, and make decisions.
Communicate effectively which includes verbal, nonverbal, as well as listening skills
Create project timelines, identify milestones, and track project progress.
Facilitates teams effectively and promotes performance improvement processes.
Design and complete data analysis methodology accurately.
Consistently function as a role model and maintain positive interactions with all customers, colleagues, supervisors, and team members.
Actively engage in professional activities.
Interprets standards and regulations related to their area of focus.
Demonstrate aptitude for compliance with VCUHS policies, procedures, and customer service philosophy.
Collaborate with project and program leaders to achieve goals.
Create and track progress reports.

Supervisory responsibilities (if applicable): N/A

Additional position requirements: N/A

Age Specific groups served: N/A

Physical Requirements (includes use of assistance devices as appropriate):
Physical Lifting: <20 lbs.
Activities: Prolonged sitting, Walking (distance), Climbing (steps, ladder, other), Reaching (overhead, extensive, repetitive), Repetitive motion
Mental/Sensory: Strong recall, Reasoning, Problem solving, Hearing, Speak clearly, Write legibly, Reading, Logical thinking, Other: Basic addition, subtraction skills
Emotional: Fast-paced environment, Steady pace, Able to handle multiple priorities, Frequent and intense customer interactions, Noisy environment, Able to adapt to frequent change

EEO Employer/Disabled/Protected Veteran/41 CFR 60-1.4.