Essential Functions & Responsibilities
Provides leadership consistent with AAAHC governance standards, ensuring the governing body maintains ultimate authority for quality of care. Implements policies, ensures organizational accountability, and maintains effective communication with leadership and medical staff.
Ensures nursing services meet AAAHC standards for quality of care, patient rights, and clinical oversight. Maintains accountability for safe, evidence-based nursing practice and competency validation.
Leads the AAAHC Quality Improvement (QI) program, ensuring ongoing, data-driven performance improvement. Oversees infection prevention, risk management, and patient safety activities consistent with AAAHC standards.
Ensures continuous compliance with AAAHC accreditation standards, CMS Conditions for Coverage, and state regulations. Maintains survey readiness and oversees policy development, review, and implementation.
Ensures financial practices support quality patient care in alignment with AAAHC expectations for organizational management and resource utilization.
Oversees billing and coding processes to ensure compliance with regulatory requirements and accurate reporting, supporting AAAHC expectations for administrative oversight.
Ensures surgical services are delivered efficiently and safely, consistent with AAAHC standards for surgical services and patient care coordination.
Maintains Environment of Care program consistent with AAAHC standards, including life safety, emergency preparedness, and equipment management.
Ensures compliance with AAAHC standards for medical records, including accuracy, confidentiality, and timely completion.
Ensures staff qualifications, training, and competency meet AAAHC human resources standards. Promotes ongoing education and performance evaluation.
Qualifications
Education
Required: BSN
Preferred: MBA or other applicable master's degree
Licenses/Certifications
Required: [Idaho] or compact state Registered Nurse
Required: Current Basic Life Support (BLS)
Preferred: ACLS and PALS within 6 months of hire
Organizational Expectations