IHS-25-RFI-DraftLC-1493358.pdf

IHS-25-RFI-DraftLC-1493358

Technical Exhibit X: Position Descriptions

1. Administrative Categories

1.1. Project Manager

1.1.1. Position Description:

Project managers organize, plan, and oversee projects to ensure they are completed on time and within budget. They plan and designate project resources, prepare budgets, monitor progress, and keep stakeholders informed. This is all done within the organization's goals and vision. Project managers are needed on a wide variety of projects, including construction, IT, HR, and marketing. Successful project managers are detail-oriented and have excellent communication skills.

Responsibilities of the Project Manager include:

• Determine and define project scope and objectives.

• Predict resources needed to reach objectives and manage resources effectively and efficiently.

• Prepare a budget based on the scope of work and resource requirements.

• Track project costs to meet a budget.

• Develop and manage a detailed project schedule and work plan.

• Provide consistent project updates to various stakeholders about strategy, adjustments, and progress.

• Manage contracts with vendors and suppliers by assigning tasks and communicating expected deliverables.

• Utilize industry best practices, techniques, and standards throughout project execution.

• Monitor progress and make adjustments as needed.

• Measure project performance to identify areas for improvement.

Project Management Professional (PMP) certification is preferred.

Minimum Qualifications: Bachelor’s Degree. More than 5 years of related experience.

1.1.2. Experience Levels:

1.1.2.1. Level I - 5-10 Years of Experience:

1.1.2.2. Level II - 10 Years of Experience: Acceptable.

1.1.2.3. Level III - Expert, more than 10 years of Experience: Acceptable

1.2. Contract Manager

1.2.1. Position Description:

Contract Managers oversee projects performed in partnership between one organization and another. They are responsible for coordinating every aspect of the project, from reviewing and approving contract terms to coordinating deadlines, approving budgets, and more.

Contract Managers work across many industries, including health care, government agencies, and more. They typically begin their careers as contract specialists and work up to management roles. The most successful Contract Managers have exceptional time management skills, strong attention to detail, and strong leadership skills.

1.2.2. Minimum Qualifications: Bachelor’s Degree in Finance, Business Management, or related field.

1.2.3. Experience Levels:

1.2.3.1. Level I - 5-10 Years of Experience:

1.2.3.2. Level II - 10 Years of Experience: Acceptable.

1.2.3.3. Level III - Expert, more than 10 years of Experience: Acceptable.

1.3. Financial Management Specialist

1.3.1. Position Description:

A Financial Management Specialist advises on financial management processes and policy and can perform cost analyses, prepare budget reports, and evaluate current accounting trends. Advises senior management team on potential strategic decisions in alignment with business objectives and legislation.

Responsibilities include:

• Advising government entities on financial operations, procedures, policies, and processes.

• Analyze financial data to identify the facility’s financial status.

• Conduct cost and benchmarking analyses.

• Prepare budget reports.

• Develop financial models, considering legal limitations, specifically Federal appropriations law and other financial management laws and regulations.

• Participate in regular audits and recommend corrective financial action plans.

• Design and review fiscal policies.

• Advise senior management team on financial planning.

• Create forecast models based on current and past financial results.

• This position will support required health policy development/documentation, perform research, report findings, and manage healthcare policies and programs as required.

Additional qualification: CPA or CFA preferred.

1.3.2. Minimum Qualifications: Bachelor’s Degree in Finance, Accounting, Business Management, or related field. At least 5 years of experience, specifically with Federal government budget or accounting.

1.3.3. Experience Levels:

1.3.3.1. Level I - 5-10 Years of Experience: Acceptable

1.3.3.2. Level II - 10 years of Experience: Acceptable

1.3.3.3. Level III - Expert, more than 10 years of Experience: Acceptable

1.4. Human Resources Specialist

1.4.1. Position Description:

The Human Resources (HR) Specialist advises on the administration of the organization's human resource systems, provides training for all employees on the correct use of the payroll system, and works with the vendor on system issues. The HR Specialist will ensure the accurate and timely application of garnishments and deductions and that payroll is processed on time.

Responsibilities for HR Specialist include:

• Advising federal government entities on human resource policies, procedures, and approaches.

• Responsible for administering the payroll system.

• Communicate with managers to resolve issues with human resource systems.

• Tracks reported issues with human resource systems and work to resolve them.

• This position will support required health policy development/documentation,

1.4.2. Minimum Qualifications: At least 5 years of experience with Federal Government Human

Resource laws, regulations, policies, and procedures.

1.4.3. Experience Levels:

1.4.3.1. Level I - 5-10 Years of Experience: Acceptable

1.4.3.2. Level II - 10 years of Experience: Acceptable

1.4.3.3. Level III - Expert, more than 10 years of Experience: Acceptable

1.5. Technical Writer

1.5.1. Position Description:

Technical writers are responsible for managing the consistency of technical written content.

Technical writers help develop and gather relevant technical information and share the completed information through an organization's communication channels, which could be internal, external, or both. Technical writers may be called upon to work with product liability specialists or customer service managers to improve the end-user experience through design changes for new products. They manage the flow of information during product development and testing processes and phases. They can also conduct usability studies to improve product design and gather research from libraries and websites, as well as their observations and discussions with technical experts. Technical writers often have a bachelor’s degree in journalism and specialized knowledge or additional degrees in medicine or computer science.

Responsibilities include:

• Updating existing documentation for both user groups (new and existing customers).

• Create illustrations, graphs, charts, and other media for materials, as needed.

• Develop content that is consistent with company branding and style guidelines.

• Consistently meet program and quality objectives for technical orders.

• Work with developers to produce quality documentation and training materials.

• Under general direction, write technical copy for various documents for a program/project of similar complexity.

• Revise documents according to internal specifications and client feedback.

• Build presentations and project documentation as requested using government-furnished software.

• Update spreadsheets daily on the status of workflow products.

• Lead proposal development efforts, working closely with a capture manager.

• Prepare and maintain operations documentation, user guides, manuals, and technical publications.

• The technical writer will develop outlines and drafts for review and approval by technical specialists and project management.

1.5.2. Minimum Qualifications: Bachelor’s Degree.

1.5.3. Experience Levels:

1.5.3.1. Level I - 5-10 Years of Experience: Acceptable.

1.5.3.2. Level II - 10 years of Experience: Acceptable.

1.5.3.3. Level III - Expert, more than 10 years of Experience: Acceptable.

2. Subject Matter Expert Specializing in Accreditation

All Subject Matter Experts (SMEs) must have experience with accreditation standards, CMS CoP, and health policy.

2.1. Accreditation Specialist

2.1.1. Position Description:

The Accreditation Specialist position collaborates with medical staff and leadership to provide a global, unified perspective and understanding of accreditation, regulatory, and disease-specific certification requirements and activities. The position serves the hospital as a resource, mentor, and educator for regulatory, accreditation, and certification programs;

works across the facility to assess, measure, and report ongoing compliance with standards, promote evidence-based best practices, and standardize common survey processes. The accreditation specialist must be able to design/redesign hospital procedures and policies to comply with accreditation standards, as appropriate to the facility, including the AAAHC and TJC standards and elements of performance and CMS Conditions of Participation.

Responsibilities include:

• Collaborates and effectively communicates with various disciplines within the facility to evaluate, improve, and sustain regulatory and accreditation readiness.

Fosters cooperation among departments and disciplines to achieve and maintain ongoing accreditation and regulatory compliance.

• In partnership with hospital leadership, the specialist establishes a process to conduct a proactive review of regulatory, accreditation, and certification to assess vulnerabilities to compliance with standards.

• Collaborates with hospital leadership to assign teams to develop corrective action in response to survey findings and facilitate the development and implementation of the corrective action processes.

• Supports and participates in hospital pre-survey, on-site survey, and post-survey activities for accreditation, regulatory, and disease-specific certification programs.

Coordinates and participates in internal surveys using evidence-based process audit tools and techniques to assess and evaluate ongoing survey readiness.

• Communicates survey findings to hospital leadership. Provides support and guidance for survey follow-up, including review and feedback related to corrective action plans.

• Provides education and training related to regulatory, accreditation, and disease-specific certification requirements.

• Functions as a liaison with accreditation and regulatory agencies, such as serving as the first point of contact and updating facility profile information.

• Facilitates resolution of survey nonconformities through monitoring the progress of corrective action plans on an ongoing basis. Conducts internal surveys with facility survey teams to review and evaluate the implementation, effectiveness, and sustainability of survey corrective action plans; develops reports from the surveys to hospital leadership on the status of survey findings' resolution and progress.

• Participates in developing, reviewing, and evaluating an ongoing regulatory and accreditation program that promotes continual improvement of compliance with standard requirements.

• Conducts ongoing monitoring, measurement, and analysis of survey data and trends; communicates aggregate results and analysis to appropriate hospital department staff and leadership.

• Utilizes efficient and cost-effective work practices with department resources and supplies; recommends reducing expenses.

• Communicates innovative and best practices to hospital quality and patient safety departments and leadership.

• Enhances continual improvement activities by acquiring, utilizing, and teaching performance improvement concepts and techniques, such as Model of Improvement and LEAN.

• This position will support required health policy development/documentation, Master's degree preferred in healthcare administration, nursing, or a related field.

Licenses and Certifications Preferred: CPHQ - Certified Professional in Healthcare Quality (NAHQ), Certified Quality Technician-ASQ, HACP - Healthcare Accreditation Certification Program (CIHQ), or CSHA - Certification Specialist in Healthcare Accreditation.

2.1.2. Minimum Qualifications: Bachelor's degree in healthcare administration, nursing, or a related field. All Professionals must have a current professional license. All providers must be board-certified in the area of subject matter expertise. SMEs must have accreditation and health policy experience.

2.1.3. Experience Levels:

2.1.3.1. Level II - 10 Years of Experience: Acceptable

2.1.3.2. Level III - Expert, more than 10 Years of Experience: Acceptable

2.2. Healthcare Quality Management and Improvement Specialist

2.2.1. Position Description:

Healthcare Quality Improvement Manager leads and manages quality improvement initiatives across healthcare organizations, working closely with clinical and administrative staff to identify areas for improvement, develop strategies, and implement changes to enhance patient care and safety. Expertise in quality management, data analysis, and process improvement will be crucial in providing the highest standard of care. The ideal candidate will have a strong background in healthcare quality improvement, excellent communication skills, and a passion for positively impacting patient outcomes. This involves working with hospitals and ambulatory clinics. Such tasks include assisting in the development of policies and procedures; designing and optimizing workflows, processes, and systems; monitoring and reporting on key performance indicators and outcomes;

accreditation; ensuring compliance with regulations, standards, and industry best practices;

communicating and collaborating with hospital staff; identifying and resolving problems and issues; as well as leading and facilitating change and improvement initiatives.

Responsibilities include:

• Lead and manage quality improvement initiatives across the organization.

• Collaborate with clinical and administrative staff to identify areas for improvement.

• Develop and implement strategies to enhance patient care and safety.

• Analyze data to identify trends and areas for improvement.

• Ensure compliance with regulatory requirements and industry best practices.

• Develop and deliver training programs on quality improvement processes.

• Monitor and report on the progress of quality improvement initiatives.

• Facilitate cross-functional teams to achieve quality improvement goals.

• Conduct root cause analysis and develop corrective action plans.

• Prepare and present reports to senior management and stakeholders.

• Stay current with industry trends and advancements in quality improvement.

• Develop and maintain quality improvement documentation and records.

• Coordinate with external agencies and accrediting bodies as needed.

• Promote a culture of continuous improvement within the organization.

• Evaluate the effectiveness of quality improvement initiatives and make adjustments as needed.

• This position will support required health policy development/documentation, performing research, reporting findings, and managing healthcare policies and programs as required.

Master's degree preferred in healthcare administration, nursing, or a related field.

2.2.2. Minimum Qualifications: Bachelor's degree in healthcare administration, nursing, or a related field. All Professionals must have a current professional license. All providers must be board-certified in the area of subject matter expertise. SMEs must have accreditation and health policy experience.

2.2.3. Experience Levels:

2.2.3.1. Level II - 10 Years of Experience: Acceptable

2.2.3.2. Level III - Expert, more than 10 Years of Experience: Acceptable

2.3. Nursing Support Specialist (License and certifications based on needs of Facility)

2.3.1. Position Description:

Nursing Support Specialists should be capable of performing a diverse range of specialized nursing duties. Top-notch candidates provide advanced and cost-effective patient care by expertly coordinating available resources.

Responsibilities include:

• Optimizing patient care by supervising nursing staff.

• Performing health assessments and developing specialized treatment plans.

• Developing nursing practices, policies, and procedures.

• Considering differential diagnoses and making clinical recommendations.

• Administering medication and treatment in consultations with patient care managers.

• Identifying training needs and facilitating training for nursing students and staff.

• Allocating staff and resources to where they are needed.

• Consulting with patients and their families to best manage their conditions.

• Staying current with the latest developments in nursing practice and contributing to medical research.

• This position will support required health policy development/documentation,

2.3.2. Minimum Qualifications: Master of Science in Nursing Degree (MSN), or a related doctorate. All nurses must be certified by the appropriate professional organization of expertise. More than 5 years of related experience. Obtained a passing score in the National Council Licensure Examination for Registered Nurses (NCLEX-RN). American Nurses Credentialing Center (ANCC)-certified CNS, toward training nursing staff. State-approved licensing to practice as a licensed and registered nurse. Specialized experience includes holding a nursing leadership role in the hospital environment for at least one year (Chief Nurse Executive, department manager or deputy, etc). SMEs must have accreditation and

2.3.3. Experience Levels:

2.3.3.1. Level II - 10 Years of Experience

2.3.3.2. Level III - Expert, more than 10 Years of Experience: Acceptable

2.4. Healthcare Industrial Hygienist or Occupational Safety and Health Specialist

2.4.1. Position Description:

Healthcare Industrial Hygienists or Occupational Safety and Health Specialists develop and maintain critical elements of the Environment of Care and Fire/Life Safety programs to ensure regulatory compliance and a safe environment at healthcare facilities. This position does not directly manage any caregivers.

Responsibilities include:

• Coordinates compliance related to Environment of Care, Disaster Preparedness, and Safety functions. This includes data entry for Environment of Care Reports, maintenance of the safety inspection process, meeting preparation, agenda development, recording and documentation of meeting minutes, and maintenance of action logs for the four essential Environment of Care or Safety Committees.

• Coordinates the Environment of Care rounds process for all SCHS facilities and serves as the Fire/Life Safety evaluator for the inspection process.

• Coordinates and monitors Fire and Life Safety program elements in compliance with Federal, State, and Local regulations.

• Manages the fire drill process, including developing scenarios, scheduling, and implementing drills to include proper documentation of the exercises. Monitors and reports compliance to operational leaders.

• Leads and facilitates regulatory survey reviews with TJC, AAAHC, State and City Fire Marshals, and CMS surveyors.

• Coordinates and monitors the progress of all action items resulting from survey activity. Escalates concerns about the Environment of the Care.

• Serves as the primary fire/life safety code interpreter. Validates regulatory findings before investing in changes or corrective actions. Collaborates with local and State fire officials, Facilities Managers, and Construction or Real Estate team members to evaluate new codes/code changes that will impact IHS facilities.

• Manages the Interim Life Safety Management program for IHS facilities. Conducts Pre-Construction Risk Assessments to evaluate for life safety deficiencies during construction and renovation projects. Develops mitigation plans, including educating clinical teams on the impacts of life safety deficiencies.

• Prepares and presents practical employee training on proper fire/life safety response procedures; documents training dates.

• Oversees Hazardous Materials/Hazardous Waste Management plans and ensures compliance with all accrediting and regulatory agencies.

• Conducts periodic assessments of hazardous substance generation and storage areas and evaluates hazardous materials handling procedures.

• Coordinates with departments regarding the proper in-house transportation, storage, and disposal of hazardous materials.

• Responsible for the Hazardous Waste Program to ensure that hazardous waste is handled correctly, contained, stored, and labeled in compliance with federal, state, and local regulatory requirements.

• Represents facility when coordinating with licensed hazardous waste haulers and other related service providers and maintains manifests.

• Conducts the mandatory annual Fire Marshal report for each County to document hazardous materials that may impact response teams during a fire event.

• Maintains Safety Data Sheet database (currently Dolphin) for all facilities.

• Coordinates monitoring process for introduction of new chemicals into facilities.

• Prepares and presents practical employee training on the safe management of hazardous materials and emergency responses, including spill response team and patient/victim decontamination team; documents training dates.

• Supports the organization's vision, mission, and values.

• Supports principles of continuous improvement with energy and enthusiasm, functioning as a champion of change.

• Provides and maintains a safe environment for caregivers, patients, and guests.

• Conducts all activities with the highest standards of professionalism and Complies with all applicable laws, regulations, policies, and procedures, supporting the organization’s corporate integrity efforts by acting ethically and appropriately, reporting known or suspected violations of relevant rules, and cooperating fully with all organizational investigations and proceedings.

• This position will support required health policy development/documentation, needed.

2.4.2. Minimum Qualifications: Bachelor's degree in safety or occupational health fields (safety, occupational health, industrial hygiene), or degree in other related fields that included or was supplemented by at least 30 semester hours of study from among the following (or closely related) disciplines: safety, occupational health, industrial hygiene, occupational medicine, toxicology, public health, mathematics, physics, chemistry, biological sciences, engineering, and industrial psychology. A professional credential as a Certified Industrial Hygienist (CIH) or Certified Safety Professional (CSP). SMEs must have accreditation and

2.4.3. Experience Levels:

2.4.3.1. Level II - 10 Years of Experience: Acceptable

2.4.3.2. Level III - Expert, more than 10 Years of Experience: Acceptable

2.5. Healthcare Engineer

2.5.1. Position Description:

A Healthcare Engineer provides a safe, reliable, and precisely controlled operating environment for direct patient care. They serve as experts in designing, sustaining, and improving the medical care environment, including all hospital building features, automated building management and environmental control systems, critical utility systems, and medical equipment technology.

Responsibilities include:

• Designs for health care equipment.

• Ensures proper functioning of fire protection systems, including selection, design, installation, inspection, testing, and maintenance

• Maintain compliance with codes and standards, occupancy and hazard classifications, fire test methods, and the interpretation of fire test data

• Collaborates directly with executive leadership, medical staff, nursing staff, and other clinical personnel regarding the design and operation of the environment for medical care.

• Educates and advises clinical staff on the safe use of critical building features, utility systems, and fire prevention systems in the environment of care.

• Performs diagnostic tests on life safety equipment and utilizes them for quality assurance.

• Plans, organizes, directs, evaluates, and manages processes for service line programs, which include setting qualitative and quantitative standards

• Oversees maintenance teams and supervises repairs to the healthcare environment.

• This position will support required health policy development/documentation, perform research, report findings, and manage healthcare policies and programs as needed.

• Applies engineering concepts and methodologies to enhance healthcare delivery by providing a technologically advanced, safe, and reliable healthcare environment.

2.5.2. Minimum Qualifications: Bachelor's degree in a discipline such as mechanical, industrial, or life safety engineering. A credential as a Professional Engineer (PE) or a Certified Healthcare Facility Manager(CHFM). SMEs must have accreditation and health policy experience.

2.5.3. Experience Levels:

2.5.3.1. Level II - 10 years of Experience: Acceptable

2.5.3.2. Level III - Expert, more than 10 years of Experience: Acceptable

2.6. Infection Prevention and Control Specialist

2.6.1. Position Description:

Infection Prevention and Control Specialist develops and implements infection control policies, including sterilization and high and low-level disinfection processes designed to reduce or eliminate outbreaks in the facility. Develops and implements facility-wide infection prevention and control measures to protect patients, staff, and visitors. Specialists monitor patient care for compliance with established standards and IHS National Policy and investigate known or suspected sources of infections to determine the source and ensure control. Develops and provides related education to staff. Additionally, the Specialist complies with state, federal, and TJC/AAAHC standards relating to infection control. This position will support required policy development/documentation, perform research, report findings, and manage healthcare policies and programs as needed.

• Ensures the need for Infection Control resources is communicated to facility leadership.

• Develops and implements practices to comply with IHS IHM 3-33 Infection Control and Prevention Policy.

• Implements strategies for improving infection prevention and control practices, using evidence-based national guidelines, with the goal of risk mitigation and patient safety.

• Implements Infection Control activities across the entire facility (medical and dental) to maximize compliance with Accreditation Standards.

• Performs activities to monitor compliance with program activities (e.g., Infection Control Environment of Care audits facility-wide).

• Utilizes the Joint Commission Resources portal auditing tools to document Infection Control tracers and activities.

• Guides staff at all levels based on federal regulations, CDC guidelines, OSHA, and accreditation standards.

• Supports patient, visitor, and staff knowledge by providing education via various methods, e.g., pamphlets, huddles, training briefs, checklists, tools, policies/Standard Operating Procedures (SOP).

• Ensures the facility has a plan to address all AAAHC and TJC standards and elements of performance.

• Implements training and competency activities for staff in high-risk processes (e.g., instrument handling and management, including sterilization and high-level disinfection).

• Monitors care and management of instrumentation and equipment (cleaning, disinfection, and sterilization processes) and ensures practices are in accordance with the Association for the Advancement of Medical Instrumentation (AAMI) and the manufacturer’s instructions for use (IFU).

• Collaborates with other facility subject matter experts and departments (such as Facilities, Industrial Hygiene, Patient Safety, Risk Management, department leaders, etc.) to conduct risk assessments, develop plans for improvement of infection control practices, or during follow-up response to high-risk events.

• Participates in and contributes to facility-level committees, providing updates to leadership as needed to ensure awareness of infection prevention and control program high-risk processes and activities (including, but not limited to, EOC, Quality Council, and Water Management Team).

• Facilitates the facility’s Infection Prevention and Control Committee, holding routine meetings (at least quarterly), ensuring an annual Infection Control Risk Assessment, an annual evaluation of the Infection Control program, and an Annual Plan to address facility risks. Ensures documentation of meeting minutes.

• Performs prevention and surveillance activities, including monitoring and NHSN reporting for healthcare-associated infections, including but not limited to C. diff, MRSA, Central line-associated Bloodstream Infection (CLABSI), Catheter-associated Urinary Tract Infection (CAUTI), Surgical Site Infection (SSI), and Respiratory Infection Data. Also collects and reports staff illness and prevention data (e.g., vaccination against influenza).

• Performs investigations and follow-up related to healthcare-associated outbreaks, collaborating with local, state, or national public health authorities as needed or required, with access to and use of public health and safety data.

• Monitors storage and disposal of infectious waste, ensuring compliance with state and federal guidance and regulations.

• Ensures staff hand hygiene compliance monitoring, with a plan for improvement.

• Collaborates with other subject matter experts on policies related to preparedness for pandemic/high-consequence infectious diseases or special pathogens/influx of infectious patients.

2.6.2. Minimum Qualifications: Bachelor's degree in a related field. All Professionals must have a current professional license. All providers must be board-certified in the area of subject matter expertise. SMEs must have accreditation and health policy experience.

2.6.3. Experience Levels:

2.6.3.1. Level II - 10 years of Experience: Acceptable

2.6.3.2. Level III - Expert, more than 10 years of Experience: Acceptable

2.7. Health Administration Specialist

2.7.1. Position Description:

Healthcare administration involves running the healthcare business. The field encompasses all the nonclinical functions that must happen to keep practices running smoothly, protect patients’ data, and keep the facility’s lights on. Healthcare administrators, also called medical and health services managers or healthcare executives, typically focus on particular areas, such as informatics, executive leadership, or insurance. Within these focus areas, they help the system run seamlessly and better serve patients, providers, and places of care.

Healthcare administrators work in various settings, including nursing and residential care facilities and private practices. They may also work in the government or outpatient care centers.

Responsibilities include:

• Communicating with and between medical staff members and executives.

• Developing departmental goals and objectives.

• Ensuring compliance with laws and regulations in their facilities.

• Improving efficiency and quality in healthcare service delivery.

• Keeping records of their facilities’ services (e.g., number of ventilators used).

• Managing the budget and finances of their facilities.

• Recruiting, training, supervising, and scheduling staff.

• This position will support required health policy development/documentation, Preferred: Master’s or PhD in healthcare administration or related field.

2.7.2. Minimum Qualifications: Bachelor’s in healthcare administration or related field. All Professionals must have a current professional license. All providers must be board-certified in the area of subject matter expertise. SMEs must have accreditation and health

2.7.3. Experience Levels:

2.7.3.1. Level II - 10 years of Experience: Acceptable

2.7.3.2. Level III - Expert, 10 years of Experience: Acceptable

2.8. Healthcare Executive Management Specialist

2.8.1. Position Description:

A healthcare executive is responsible for setting a healthcare organization's vision, mission, and goals, such as a hospital, clinic, health system, or medical group. They also plan, implement, and evaluate the policies, programs, and services that support the organization's objectives. A medical executive works with various stakeholders to ensure quality, safety, efficiency, and financial stability.

Responsibilities include developing and managing the budget and financial performance of the organization, negotiating contracts and agreements with external partners and suppliers, hiring and training senior managers and directors, communicating and collaborating with the board of directors and other executives, monitoring and improving clinical outcomes and patient satisfaction of the organization, leading change management and innovation initiatives, and addressing any issues or conflicts that arise within or outside the organization. This position will support required health policy development/documentation, perform research, report findings, and manage healthcare policies and programs as needed.

The ability to evaluate processes, procedures, and capacities and train IHS staff in these functional areas is essential.

2.8.2. Minimum Qualifications: Bachelor’s in healthcare administration or related field. All

2.8.3. Experience Levels:

2.8.3.1. Level II - 10 Years of Experience: Acceptable

2.8.3.2. Level III - Expert, 10 years of Experience: Acceptable

2.9. Compliance Specialist

2.9.1. Position Description:

A compliance specialist ensures the organization adheres to all applicable laws, regulations, and policies. They are responsible for developing, implementing, and monitoring compliance programs that help the organization stay within legal and ethical boundaries.

Responsibilities include:

• Developing and implementing compliance programs: Compliance officers create programs that ensure their organization complies with all relevant laws and regulations.

• Monitoring compliance: They also monitor the organization’s adherence to regulations, policies, and procedures — and identify potential risk areas.

• Educating employees: Compliance officers inform employees of the importance of compliance and provide training on relevant regulations and policies.

• Investigating complaints: When a compliance issue arises, HCOs investigate the matter to identify the root cause and recommend corrective action.

• Developing corrective action plans: Compliance officers work with leadership to develop and implement disciplinary action plans to address recurring issues.

• This position will support required health policy development/documentation,

2.9.2. Minimum Qualifications: Bachelor’s in healthcare administration or related field. All

2.9.3. Experience Levels:

2.9.3.1. Level II - 10 years of Experience: Acceptable.

2.9.3.2. Level III - Expert, more than 10 years: Acceptable

2.10. Physician Executive

2.10.1. Position Description:

A Physician Executive is a healthcare leader who combines clinical expertise with healthcare leadership. They possess a deep understanding of medical practice, patient care, and healthcare systems, complemented by strong leadership, communication, and decision-making abilities. A successful Physician Executive maintains an active license as an MD or DO, possesses significant clinical experience with board certification in a relevant specialty, leverages advanced training in healthcare management (such as an MBA, MHA, MPH, or CPE certificate), and draws on proven experience in prior healthcare executive and leadership roles.

• Strategic Leadership: Aligns clinical and administrative functions with the organization's overall mission, goals, and objectives and bridges between clinical staff and leadership to ensure the mission and vision of the organization are met.

Effectively communicates strategy and vision to different stakeholders, such as leadership, clinical staff, and external stakeholders, such as community and regulatory agencies, orally and in written format. Writes effective strategic documents, health policies, and healthcare procedures.

• Clinical Governance: This position ensures the delivery of high-quality, patient-centered care by establishing and optimizing clinical governance. Examples include, but are not limited to, creating, updating, and implementing Medical Staff Bylaws, clinical committees, peer review programs, and credentialing and privileging programs.

• Clinical Leadership and Team Development: Develop sustainable clinical teams that deliver high-quality, patient-centered care. This is achieved via clinical leadership coaching, practical communication skills, fostering excellence in clinical knowledge and skills, and comprehensive staffing expertise, including recruitment, retention, and management of underperforming practitioners.

• Data-driven Decision Making: Models data-driven decision-making by bringing expertise in the creation, sourcing, selection, and interpretation of business, enterprise, and clinical metrics.

• Clinical Quality and Risk Management: This position ensures clinical quality and patient safety and mitigates clinical risk using industry-standard approaches such as quality assurance, audits and internal control, quality improvement methodology, data analysis, medical quality review, and medicolegal expertise.

• Financial Stewardship: Ensure financial sustainability via expert budget management and a strong capacity to optimize the revenue cycle, particularly revenue capture.

• Stakeholder Engagement: Engages patients to ensure patient-centered decisions are reflected throughout the organization. Understands industry standards for patient engagement and patient surveying and formulates effective plans to ensure strong engagement and exceptional patient experiences.

• Crisis Management. Prepares and maintains operations during crisis, ensuring operations and disaster recovery continuity in varied emergencies such as a public health emergency, cybersecurity breach, weather emergency, and/or severe staffing challenges.

• Regulatory Compliance. Understands and maintains expert knowledge of regulatory and accreditation requirements to maintain operations, including but not limited to TJC, CMS CoP, AAAHC, PMCH designation, and laboratory accreditation.

2.10.2. Minimum Qualifications:

2.10.2.1. Active, unencumbered medical license (MD or DO)

2.10.2.2. Current Board Certification (ABMS or AOA) in relevant specialty

2.10.2.3. Advanced degree or certification in healthcare management (e.g., MBA, MHA, MPH, CPE certification)

2.10.2.4. Executive Experience in Healthcare

2.10.2.5. Clinical Experience

2.10.2.6. Accreditation and health policy experience.

2.10.3. Experience Levels:

2.10.3.1. Level II - 10 years of Experience: Acceptable

2.10.3.2. Level III - Expert, more than 10 years of Experience: Acceptable

2.11. Behavioral Health Management Specialist

2.11.1. Position Description:

A Behavioral Health Management Specialist is responsible for counseling and treating patients with behavioral issues. Their responsibilities revolve around conducting initial assessments through interviews and observation, maintaining records and data, developing treatment plans, and referring patients to other support services when necessary. Moreover, a behavioral health specialist must communicate with the patient's family or guardians, discuss conditions, and provide advice on taking care of them. Aside from treating patients, it is also essential to continuously monitor their behavior while building positive relationships with them.

Responsibilities include:

• Providing individualized intervention for problematic behaviors using therapeutic crisis intervention (TCI) techniques, such as de-escalation, to prevent and/or manage crisis.

• Monitor meals for residents suffering from eating disorders and offer compassion and encouragement to individuals who struggle with eating.

• Provide detailed reports daily and weekly on the interaction between the client and the behavioral health provider (BHP).

• Redirect negative or harmful behavior and encourage patients to utilize dialectical behavioral therapy (DBT) skills.

• Work closely with clinical staff to ensure compliance with HIPAA and privacy regulations.

• Ensure proper documentation of patient status to comply with HIPAA.

• This position will support required health policy development/documentation,

2.11.2. Minimum Qualifications: All Professionals must have a current professional license.

All providers must be board-certified in the area of subject matter expertise. SMEs must have accreditation and health policy experience.

2.11.3. Experience Levels:

2.11.3.1. Level II - 10 Years of Experience: Acceptable

2.11.3.2. Level III - Expert, more than 10 years of Experience: Acceptable

2.12. Credentialing Specialist

2.12.1. Position Description:

A Credentialing Specialist, or Physician Credentials Verification Coordinator, provides administrative assistance and verifies licenses and credentials in the healthcare industry.

Their duties include keeping detailed records of medical staff members, maintaining databases, and ensuring staff members possess legal licenses and credentials to work in their chosen fields. They must also ensure that every staff member is legally licensed and/or credentialed and up to date with the latest medical policies and procedures.

Responsibilities include:

• Creates and maintains licensing, credentials, and insurance records.

• Researches updated state and federal regulations and policies.

• Releases information to requesting agencies and public inquiries when required by law.

• Helps to develop internal credentialing processes.

• Monitors license and credential expiration dates and advises staff members of required “renew by” dates.

• Ensures the facility and staff members are maintaining compliance with regulatory and accrediting institutions.

• This position will support required health policy development/documentation,

2.12.2. Minimum Qualifications: All Professionals must have a current professional license.

All providers must be board-certified in the area of subject matter expertise. SMEs must

2.12.3. Experience Levels:

2.12.3.1. Level II - 10 years of Experience: Acceptable

2.12.3.2. Level III – Expert, more than 10 years of Experience: Acceptable

2.13. Health Policy Specialist

2.13.1. Position Description:

Health Policy Specialists perform research, report findings, and manage healthcare policies and programs. They develop health policies using information collected and analyzed by healthcare professionals.

Preferred Master's degree or certification in health policy or related field.

2.13.2. Minimum Qualifications: Bachelor's degree in a relevant field, such as healthcare policy or a related field. All Professionals must have a current professional license. All providers must be board-certified in the area of subject matter expertise. SMEs must have accreditation and health policy experience.

2.13.3. Experience Levels:

2.13.3.1. Level II - 10 years of Experience: Acceptable

2.13.3.2. Level III – Expert, more than 10 years of Experience: Acceptable

2.14. Clinical Informatics Specialist

2.14.1. Position Description:

Clinical Informatics specialists use healthcare and IT experience to design, modify, and develop computerized systems, keeping them running as efficiently, effectively, and securely as possible. Clinical informatics specialists are responsible for building and teaching user interfaces to healthcare organization staff, implementing plans to improve patient records management systems, and facilitating communication between the IT team, healthcare providers, and other stakeholders.

Responsibilities include:

• Designs user interfaces to store and evaluate patient and organization data.

• Creating and implementing a plan to keep the organization’s information, digital security, and registries current.

• Troubleshoots software and hardware problems to make sure patient care runs smoothly.

• Review existing systems and suggest improvements.

• Trains staff to remain compliant with the company’s security, data, and patient care standards.

• Analyzes, cleans, standardizes, and prepares data for analysis.

• Documents progress to report to supervisors and stakeholders regularly.

• This position will support required health policy development/documentation,

2.14.2. Minimum Qualifications: Bachelor's degree in a relevant field. All Professionals must have a current professional license. All providers must be board-certified in the area of subject matter expertise. SMEs must have accreditation and health policy experience.

2.14.3. Experience Levels:

2.14.3.1. Level II - 10 years of Experience: Acceptable

2.14.3.2. Level III - Expert, more than 10 years of Experience: Acceptable

2.15. Healthcare Leadership / Governance Specialist

2.15.1. Position Description:

Healthcare leadership involves directing the activities of a group toward a shared goal. The key aspects of the leadership role include influencing group activities and coping with change. Numerous groups with associated subcultures might support or conflict with each other. Leadership must capitalize on the organization's diversity and efficiently utilize resources when designing management processes while encouraging personnel to work towards common goals. Several leadership approaches can be adapted to the healthcare setting to optimize management in this highly complex environment. This position would be an expert in this field, able to assess leaders' performance, train and mentor them, and carry out related activities.

Governance is a framework that accounts for all the processes of governing organizations and businesses. It’s a structure that holds governing boards and leaders accountable for continuously improving operations, clinical staff and processes, society, and financial performance. A healthcare board of directors and executive management are in charge of all aspects of corporate governance. Another aspect of governance is the clinical side, which includes caring for patients, managing clinical practices, and administration. The role of governance in healthcare organizations looks a bit different than it does in other types of industries. This position would be an expert in this field, able to assess the performance of leadership and governing boards of healthcare facilities, identify critical process improvements, and assist in developing health and sustainable communication and decision-making strategies. This position will support required health policy development/documentation, perform research, report findings, and manage healthcare policies and programs as needed.

2.15.2. Minimum Qualifications: Master's degree or better degree in quality management, health care management, or related field. All Professionals must have a current professional license. All providers must be board-certified in the area of subject matter expertise. SMEs must have accreditation and health policy experience.

2.15.3. Experience Levels:

2.15.3.1. Level II - 10 years of Experience: Acceptable

2.15.3.2. Level III - Expert, more than 10 years of Experience: Acceptable

2.16. Enterprise Risk Management Specialist

2.16.1. Position Description:

An Enterprise Risk Management Specialist has a proven track record in understanding and implementing enterprise and operational risk best practices and knowledge of key regulatory requirements, assessing risks, and improving controls within the federal sector.

The duties include analyzing financial reports, market research, and operating procedures, strategizing ideas to improve business operations, and meeting with company executives and other stakeholders to provide suggestions based on their analysis. The Specialist will be able to help IHS facilities:

• Collaborate with stakeholders to gather, analyze, and document business requirements for enterprise risk management (ERM) and compliance.

• Translate business requirements into system requirements to provide to system integrators.

• Conduct thorough assessments of existing processes, systems, and controls to identify potential risks and compliance gaps.

• Develop and implement strategies for improving processes and controls to mitigate risks better and comply with regulatory requirements, including, but not limited to, (specify relevant regulations or standards).

• Design and maintain comprehensive documentation of risk management procedures and controls.

• Partner with cross-functional teams to integrate risk management and compliance processes into an enterprise Governance, Risk, and Compliance (GRC) solution.

• Proactively identify and manage project risks, issues, and key dependencies and recommend appropriate actions.

• This position will support required health policy development/documentation,

2.16.2. Minimum Qualifications: The minimum educational requirement is a bachelor's degree in a related field. All Professionals must have a current professional license and be board-certified in the area of subject matter expertise in ancillary support. SMEs must have

2.16.3. Experience levels

2.16.3.1. Level II - 10 years of Experience: Acceptable

2.16.3.2. Level III – Expert, more than 10 years of Experience: Acceptable

2.17. Ancillary Support Specialist

2.17.1. Position Description:

An ancillary support specialist will support ancillary services within facilities and is responsible for examining the efficiency of existing processes and policies, laying the groundwork for improvement opportunities, or establishing new programs to meet accreditation and industry standards. The position's duties include reviewing and amending policy drafts and proposing suggestions to improve the effects of existing policies. The Ancillary support specialist also works closely with hospital staff to determine the goals and objectives of policies.

The ancillary support specialist will have knowledge, skills, and abilities in specified ancillary departments, including laboratory, radiology, physical therapy, occupational therapy, and dietary services.

Responsibilities include:

• Provides guidance on accreditation requirements – CLIA, TJC including but not limited to:

o Testing procedures and valid testing methods o Quality assurance procedures o Equipment calibrated and maintained according to IFLU o Staff training o Competency training o This position will support required health policy development/documentation, perform research, report findings, and manage healthcare policies and…