Provides the day to day communication and oversight of the Health System's Quality and Evaluation Services (QES) functions which includes performance improvment efforts; patient rights program; Joint Commission Accreditation of Healthcare Organizations(JCAHO) and state/federal regulatory surveys and compliance; risk management;safety; clinical policy review and administration; and the daily oversight and coordination of functions associated with the management of medical/school records. Provides effective liaison and reporting to the Director, Division of QES or designee, so that quality performance improvement, safety, and other date can be included in Health System reports and to ensure consistant system-wide practices, goals, and objectives. Investigates or assists in the investigation of complaints and concerns as needed. Work requires comprehensive knowledge of health care administration and its governing laws and effective oral and written communication skills - aquired through a Masters degree in Social Work, Public Health, or related field of study, or through a bachelors degree plus an additional two years experience in addition to the experience requirements listed below. Work requires comprehensive knowledge of the requirements and review process of JCAHO and state regulatory agencies; demonstrated experience with reseaching and planning for regulatory and acceditation reviews; knowledge of the laws and regulations pertaining to patients' rights, and comprehensive knowledge of performance improvement process - aquired through three to five years of related work experience. Work requires analytical skills sufficient to research, interpret, and apply written statutes, regulations, policies, and accedidation requirements, and to synthesize, report and develop recommendations from data.