Experience in interpretation of raw data and comparative analysis, experience in conducting educational in- services, experience in coordinating and supervising accreditation/certification survey activities for the Joint Commission, CMS, State Licensure and demonstrated experience in working effectively with multiple departments on confidential issues in a positive and constructive manner. Responsible for directing quality management efforts to ensure continuous improvement and organizational excellence, adherence with all regulatory, compliance, accreditation, and legal issues, and promote a safe environment for all employees, patients and visitors.