Responsible for system wide quality, accreditation, regulatory standards, staff education and patient education programs. In collaboration with the Director, Chairman, Radiation Safety Officer and other department and organizational leaders; identifies, plan and executes activities to promote patient safety, performance improvement initiatives and to ensure compliance according to the regulatory statutes, policies and procedures. Performing professional administrative duties related to assessing, planning, implementing, auditing and evaluating performance improvement and regulatory compliance strategies for Mammography Department.
Essential Responsibilities:

* Manages Mammography quality, education and compliance programs.

* Assists in implementation of Mammography policies and procedures in conjunction with department leadership.

* Communicates and assists with ongoing quality program compliance by complying with state and federal agencies ( NJ State, ACR, MQSA, OSHA, TJC, National Quality Foundation etc.).

* Accountable for understanding regulatory and/or accreditation standard requirements needed to meet the intent, monitor and distribute future requirements to appropriate owners and stakeholders, anticipate activities necessary to become compliant, and take necessary steps to endure ongoing compliance.

* Leads in the development and implementation of a department plan for continuous readiness for regulatory compliance and accreditation based on assigned standards.

* Updates all policies annually and obtain required signatures from director and dept. chief.

* Ensures that all policies and procedures are consistent in all sites and actively enforced by the management team.

* Participates in the department Quality Committee and presents reports to the department leadership.

* Inspects each Mammography site quarterly, reviewing policy and procedure manuals, safety of equipment in collaboration with RSO, Bio-Med, and staff compliance with established policies and procedures. Partner with appropriate department leadership to develop and/or maintain activities and work plans to address areas of opportunity as needed.

* Develops the annual diagnostic imaging compliance plan and prepares quarterly updates of plan for the KPI the department leadership and represents the department on the Compliance Committee.

* Manages the Mammography and Education/Training and assists in developing quality improvement and training programs focused on achievement of the quality standards, identifying areas of excellence to emulate and training and mentoring of staff.

* Establishes clear and measurable short and long term goals, objectives, and monitors results. Ensures quality, education, and compliance strategies are aligned with business strategies relating to development and growth of new service lines.

* Partner with department operational leadership to develop department-specific quality/education interventions to improve and/or reduce variation in practice and promote efficient use of healthcare resources.

* Supports leadership in review of quality and patient safety concerns identified through peer review, near miss reporting and concerns including: Review aggregate data on routine basis and conduct root cause analysis of issues as needed; partner with department leadership to prioritize issues and develop action plans to address; document action plans and monitor results as required by regulatory and compliance guidelines.

* Collaborates in established partnerships with the PACS, IT and the biomedical department.

Basic Qualifications:
Experience

* Associate's Degree required, Bachelor's Degree preferred. License, Certification, Registration

* Recognized Imaging Science Certification (ARRT, Mammography).
Additional Requirements:

* Demonstrated facilitation and presentation skills.

* Demonstrated skills for large scale initiatives.

* Demonstrated knowledge of organizational development principles and methodologies (e.g. change management, team development, adult learning principles).

* Multi-project and management skills.

* Proven ability to work autonomously.

* Advanced oral and written communication skills.

* Demonstrated experience building, maintaining and leading team efforts and achieve Quality, Education and Compliance goals.

Preferred Board Certification in Quality Management, AART/ACR but could be obtained at a later date.

Education:

Associate's Degree required, Bachelor's Degree preferred.

Experience:

3 years experience as a Mammographer Preferred

2 years experience in a QA/QC Technologist required.

Analytical, problem solving skills required.

Required License/Certifications/ Registration:

Graduate of an JCERT approved program in Radiography, Current BLS

Current NJ RADTECH License

Current ARRT - American Registry Radiology Technology

Current Mammography credential