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Kaiser Permanente Careers

Quality Assurance, UR & Case Management

Passion + Vision + Integrity = Excellence

Ensure consistency and the highest ethical standards across our entire organization. Our quality assurance team drives ongoing improvement by fostering an environment of support, providing technical and specialized consultative services, and inspiring ongoing excellence.

Director Accreditation and Continuous Quality Improvement - Kaiser Permanente School of Medicine

Location: Pasadena, CA Additional Locations:
Job Number: 772930 Date posted: 02/14/2019

By joining the team that is designing and implementing the Kaiser Permanente School of Medicine, you will have the opportunity of a lifetime to create a medical school that will educate physicians for the 21st century and beyond and be a catalyst for change in medical education. This position will be working as a part of an extremely dynamic team of professionals supporting all aspects of the School of Medicine and the creation of the infrastructure, process, and procedures for the Kaiser Permanente School of Medicine. The team works from an interdependent model of practice and we are looking for someone who thrives in a highly challenging role within a high functioning team-based environment.

The Kaiser Permanente School of Medicine will offer more than a conventional medical education. It will provide students with the unique opportunity to be taught by the physicians of Kaiser Permanente and immersed in one the nation-s highest-performing health care organizations. Students will gain critical knowledge and real-world experience and benefit from unprecedented access to Kaiser Permanente's people, data and technology. This unparalleled approach, plus our deep commitment to resilience, well-being, and inclusion will create a culture where physicians are better prepared to face the health challenges of the future, while helping the nation-s diverse communities thrive. Learn more about the Kaiser Permanente School of Medicine at

The position of Director of Accreditation and Continuous Quality Improvement will be responsible for keeping abreast of evolving accreditation standards, overseeing the preparation and timely submission of requirements of the LCME and processes for monitoring compliance with accreditation standards and documenting continuous quality improvement initiatives. The position will also advise KPSOM leadership on matters related to LCME, program evaluations, and reviews. The position reports to the Senior Associate Dean for Medical Education (accreditation) and the Associate Dean for Assessment and Evaluation (CQI.) The position will work closely with the Assessment and Evaluation Unit which manages much of the data relevant to accreditation and program evaluation for CQI.

Essential Responsibilities:

  • Oversees the LCME accreditation processes for KPSOM.

  • Advises senior leadership on all accreditation requirements.

  • Consults with deans, faculty, course and clerkship directors, and others regarding various aspects of educational programs and administrative processes as related to accreditation and quality improvement activities of the college.

  • Ensures all LCME accreditation requirements are documented and processed in accordance with established timelines, including completion of annual reporting requirements and preparing for cyclical accreditation reviews and site visits.

  • In collaboration with the Senior Associate Dean for Medical Education, provides leadership and oversight in conducting the LCME Institutional Self-Study, including setting timelines, overseeing committee operations, developing reports, and supervising preparation of draft and final submissions of all required documents.

  • Works to ensure alignment of KPSOM website information with LCME documentation.

  • In collaboration with the Associate Dean for Assessment and Evaluation, communicates with appropriate administrators and committees to ensure alignment of accreditation requirements with CQI processes and the KPSOM Strategic Plan.

  • Manages the collection, analysis and synthesis of pertinent accreditation and quality improvement data for communication and required reporting to relevant stakeholders and the Program Evaluation, Assessment, and Improvement Committee.

  • Develops and maintains continuous quality improvement dashboards.

  • Supports Compliance Officer in completing accreditation requirements related to Bureau for Private and Post-Secondary Education (BPPE) and WASC Senior College and University Commission (WSCUSC).

  • Contributes, as directed, to the development of policies, procedures, manuals, and other written communications required as supporting documentation for each of the college's accreditation processes, including but not limited to policies and procedures, handbooks and website content.

  • Writes and edits documents in accordance with style manuals generally accepted in academia and medicine (e.g. Chicago Manual of Style, American Medical Association Manual of Style).

  • Other job-related duties as assigned.      

  • Basic Qualifications:


  • Minimum six (6) years of experience, in quality improvement and/or project management in healthcare or academic medical setting.

  • Education

    • Bachelor's Degree in Education and/or Business or four (4) years of experience in a directly related field.

    • High School Diploma or General Education Development (GED) required.

    License, Certification, Registration

  • N/A

  • Additional Requirements:

  • Proficiency with MS Office products (Work, Power Point, Excel, Exchange, and Access).

  • Ability to manipulate data within and across MS Office products (e.g., conduct Microsoft Word email merges using mail lists in Excel; import data from Excel into Access).

  • Ability to manage and prioritize multiple tasks and responsibilities with minimal supervision.

  • Intermediate-level skill and experience using Microsoft Excel including macros, external data connections, pivot tables, charts, and conditional formatting.

  • Excellent verbal and interpersonal communication skills.

  • Ability to work collaboratively with a variety of stakeholders, including project staff and faculty from a variety of disciplines and administration.

  • Ability to manage complex tasks/projects in a timely manner with a high degree of quality and to mobilize relationships and resources in a collaborative, collegial manner.

  • An entrepreneurial spirit, creative energy, and sense of humor.

  • Preferred Qualifications:

  • Experience in implementing and managing quality improvement processes

  • Advanced degree in a related field.
  • Primary Location: California,Pasadena,S. Los Robles Administration 100 S. Los Robles Ave Scheduled Weekly Hours: 40 Shift: Day Workdays: Mon, Tue, Wed, Thu, Fri Working Hours Start: 8:00 AM Working Hours End: 5:00 PM Job Schedule: Full-time Job Type: Standard Employee Status: Regular Employee Group/Union Affiliation: Salaried, Non-Union, Exempt Job Level: Director/Senior Director Job Category: QA / UR / Case Management Department: Kaiser Permanente School of Medicine Travel: Yes, 5 % of the Time Kaiser Permanente is an equal opportunity employer committed to a diverse and inclusive workforce. Applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy), age, sexual orientation, national origin, marital status, parental status, ancestry, disability, gender identity, veteran status, genetic information, other distinguishing characteristics of diversity and inclusion, or any other protected status.

    External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with federal and state laws, as well as applicable local ordinances, including but not limited to the San Francisco and Los Angeles Fair Chance Ordinances.

    About QA, Ur & Case Management Careers

    Careers In QA, Ur & Case Management

    As an organization, we are committed to delivering the same exemplary care no matter who you are, where you are, or what your needs. But how are those standards defined, measured, and assessed? That's where our quality assurance team comes in. Implementing the action plans and initiatives that will drive successful practices, you'll work across the organization to foster the necessary education, communication, and innovation that will enable us to operate as one KP — with our mission and goals in complete alignment.

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