Responsibilities The Director of Performance Improvement/ Medical Staff Administrator is responsible for assisting the CEO in required tasks including, but not limited to conducting performance audits, monitoring quality and risk trends, policy and procedure development. NP and Medical staff scheduling, credentialing oversight and staff training. Oversee the collection as well as submission of all internally and externally submitted performance measures. Ensures that the facility compliance with The Joint Commission, CMS, AHCA, OSHA and other regulatory agencies standards. Responds quickly and proactively to performance indicators and data, resulting in higher quality staff and superior patient care. Audit records to ensure documentation is completed timely, effectively and according to facility policy, to ensure facility staff is following established policies and procedure Monitor quality and risk trends, policy and procedure development, staff training and ensure compliance with regulatory standards, contracts, licensing standards and guidelines. Prepare for, and conduct the monthly PI Committee, will create and implement action plans deriving from those meetings and regulatory surveys Coordinates Medical Staff and Nurse Practitioner schedules, administratively supervises NP coverage assignments About Universal Health Services One of the nation's largest and most respected providers of hospital and healthcare services, Universal Health Services, Inc. (UHS) has built an impressive record of achievement and performance. Growing steadily since its inception into an esteemed Fortune 500 corporation, annual revenues were $15.8 billion in 2024. UHS was again recognized as one of the World's Most Admired Companies by Fortune; listed in Forbes ranking of America's Largest Public Companies. Headquartered in King of Prussia, PA, UHS has approximately 99,000 employees and continues to grow through its subsidiaries. Operating acute care hospitals, behavioral health facilities, outpatient facilities and ambulatory care access points, an insurance offering, a physician network and various related services located all over the U.S. States, Washington, D.C., Puerto Rico and the United Kingdom. www.uhs.com Qualifications Bachelor's Degree required. Master's Preferred. 3 to 5 years experience Excellent communication (verbal and written) skills are essential. A strong knowledge of Joint Commission, CMS, OSHA and Patient Rights standards, and any other applicable federal and state laws and regulations governing mental health care facilities is required. Requires good computer skills. Analysis of data to improve performance, reduce risk, and provide safe and quality patient care. Able to work independently and collegially with all clinical disciplines. Must have good time management skills EEO Statement All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws. Avoid and Report Recruitment Scams We are aware of a scam whereby imposters are posing as Recruiters from UHS, and our subsidiary hospitals and facilities. Beware of anyone requesting financial or personal information. At UHS and all our subsidiaries, our Human Resources departments and recruiters are here to help prospective candidates by matching skill set and experience with the best possible career path at UHS and our subsidiaries. During the recruitment process, no recruiter or employee will request financial or personal information (e.g., Social Security Number, credit card or bank information, etc.) from you via email. Our recruiters will not email you from a public webmail client like Hotmail, Gmail, Yahoo Mail, etc. If you suspect a fraudulent job posting or job-related email mentioning UHS or its subsidiaries, we encourage you to report such concerns to appropriate law enforcement. We encourage you to refer to legitimate UHS and UHS subsidiary career websites to verify job opportunities and not rely on unsolicited calls from recruiters.