Job Description

Harris Health is a nationally recognized health system comprising three teaching hospitals and an extensive network of ambulatory care centers serving the people of Harris County, Texas, since 1966.  Staffed by the faculty, fellows and residents from two nationally ranked medical schools, Baylor College of Medicine and The University of Texas Health Science Center at Houston (UTHealth), Harris Health is the first healthcare system in Houston to receive the prestigious National Committee for Quality Assurance (NCQA) designation for its network of patient-centered medical homes.

Each year, Harris Health provides more than 1.8 million total outpatient visits through its more than 40 ambulatory care facilities.  Additionally, Harris Health sees more than 177,000 emergency visits at its Level 1 and Level 3 trauma centers and 35,000 hospital admissions through its three hospitals: Ben Taub, LBJ and Quentin Mease.

Established by voter referendum to enhance the level of charity care available in the community, Harris Health System has often received national recognition for serving those in need and for its achievements in operational excellence, such as being named to the 2011, 2012, 2013 and 2014 Most Wired Hospitals lists by the American Hospital Association’s Hospitals & Health Networks magazine.

Additionally, Harris Health System is pleased that each of its three hospitals — Ben Taub, Lyndon B. Johnson and Quentin Mease — achieved Pathway to Excellence™ designation by the American Nurses Credentialing Center.

Skills / Requirements

Job Summary

The Administrative Director of Accreditation/Regulatory Affairs-Correctional Health is responsible for facilitation of accreditation, and regulatory activities for the Harris Health System Correctional Health organization. This position assists the Correctional Health Leadership to set the strategic direction for the division with respect to the pavilion's National Commission on Correctional Health Care (NCCHC) accreditation program, Texas Commission on Jail Standards accreditation, audits involving grant funded programs, and continual compliance with the hospital operation and licensing rules and regulations as specified by the Texas Administrative Code. This includes the management, monitoring and evaluation of Accreditation/Regulatory Affairs activities within Harris Health System and Correctional Health. The Administrative Director is responsible for the coordination and facilitation of Accreditation/Regulatory Affairs Teams during survey activities, including those not specifically listed above. Works in conjunction with Risk Management on compliance issues related to patient's complaint filed with other regulatory bodies. Responsible for establishment and maintenance of the system rounding software programs, including tool development and report generation.

Minimum Qualifications

Bachelor of Science in Nursing or a B.S. Degree in a related health field require for non-RNs.

Master's Degree in health care field preferred or in progress and Survey experience required i.e., JCAHO, TDH, CMS, NCCHC, etc. Preferred

Licenses & Certifications:
CCHP (Certified Correctional Health Professional) Preferred
Registered Nurse; Current, valid Texas License Preferred

Work Experience:
Seven plus (7+) years of experience with Quality Management; Knowledge of JCAHO and CMS surveys. Very knowledgeable about auditing processes and related policies. Including five (5) years of experience in correctional health care; acute care setting, preferably a teaching institution, with participation in at least one successful NCCHC survey for accreditation.

Management Experience:
Ten (10) years of management experience

Communication Skills: Above Average Verbal Communication (Heavy Public Contact), Exceptional Verbal (Public Speaking), Writing/Correspondence, Writing/Reports

Proficiencies: MS Word

Job Attributes

Knowledge/Skills/Abilities: Analytical, Design, Mathematics, Research, Statistical

Work Schedule: Flexible, Eligible for Telecommute, Travel

Equipment Operated: Computers, printers, copiers, fax and related software and statistical tools experience required.

Other Requirements:
a)Demonstrated leadership skills;
b) Frequent travel between hospital district pavilions required;
c) May require extended hours in addition to weekends/holidays for special projects;
d) Knowledge of contractual requirements, proposal commitments, and relevant policies/procedures;
e) Knowledge of quality control practices/procedures within a correctional facility;
f) Knowledge of site level operations and practices consistent with compliance guidelines; g) Ability to analyze data and operational reports to ensure compliance with policies, standards, and contractual requirements;
h) Ability to develop analytical reviews and evaluative processes and guidelines to utilize in measuring full compliance of Correctional Health operations.

Application Instructions

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