Director of Quality Risk and Compliance (11270)

JOB TITLE

Director of Quality Risk and Compliance

REPORTS TO

Executive Director

SUPERVISION EXERCISED

Clinical Nurse Manager

FLSA STATUS

Exempt

SALARY RANGE

$100,000 - $200,000

JOB SUMMARY

The Director of Quality, Risk and Compliance oversees the development, implementation and evaluation of the overall quality program.  This includes but is not limited to the following: 1) leads the corporation’s performance improvement process, 2) identifying performance trends, as well as 3) prioritizing, and recommending improvements, 4) leads data collection and analysis of quality improvement indicators, collaborates in quality improvement projects, and participates in the design, generation and analysis of reports for data collection related to quality support.  This position will also manage the risk management program; including risk/legal issue reporting, management of all liability claims/legal defense activities, coordinate systems for risk identification, investigation and analysis; and coordination of risk management education.  In addition, this position includes serving as the Compliance Officer who is responsible for developing, administrating and implementing the organization’s Compliance Program.

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Effectively organizes and implements the QA/RM Program which includes but not limited to:
  • Monitors patient and customer satisfaction,
  • Manages organizational event reporting and follow-up for clinical risk issues,
  • Facilitates the QA/QI Committee,
  • Organizes Medical and Dental Peer Reviews
• Investigates medical liability claims and keeps the administrative team informed of progress
• Prioritizes performance improvement projects
• Provides guidance and support regarding HIPAA, privacy, security, compliance, risk management, and operational legal concerns in collaboration with appropriate internal and external resources.
• Participates in investigations, corrective action planning, and resolution of operational concerns, patient complaints, compliance issues, and risk management matters as appropriate.
• Acts as Privacy Officer responsible for the development and implementation of policies and procedures relating to the Privacy & Security Policy Manual
• Develops organizational emergency preparedness activities, business continuity planning, and clinic operational response during emergencies and unforeseen events. Collaborates with all service lines and other staff in the design and implementation of QA/RM activities
• Provides reports to senior management and the Board of Directors for QA, RM, and compliance activities in conjunction with appropriate service directors
• Compiles statistical data and writes narrative reports summarizing QA findings
• Reviews and prepares organizational policies for QA Committee
• Effectively communicates findings of QA/RM activities to staff, administration, and departments
• Maintains current and accurate records of all relevant communications, audits, and corrective action plans
• Develops, implements, and coordinates emergency preparedness activities
• Works with the Director of Operation, and Office Managers, to evaluate operations at each site and identify areas for improvement
• Participates with management team to identify /respond to needs in service area
• Develops and organizes QA, RM, and Compliance educational programs for staff
• Works closely with Care Coordination Team and Information Technology
• Ensures the integration of strategic, operational goals and programs such as Patient Centered Medical Home, UDS, and OneCare.
• Oversees the QA/QI program established by board approved policies to include ensuring the implementation of the QA/QI operating procedures and related assessments, monitoring QA/QI outcomes, and updating QA/QI operating procedures.
• Responsible for maintaining compliance for FTCA approval along with meeting the annual deeming submission requirements.
• Performs other duties as assigned

KNOWLEDGE, SKILLS, AND ABILITIES

• Knowledge of state and federal regulations

• Knowledge and experience with quality improvement processes and chart auditing
• Knowledge of Microsoft Office
• Knowledge of medical terminology
• Knowledge of OSHA manual and standards, including appropriate hazardous waste handling and disposal
• Ability to juggle multiple tasks and prioritize workload
• Strong communication and interpersonal skills
• Ability to use computerized support systems

EDUCATION

Associate’s or Bachelor’s Degree

EXPERIENCE

1 year clinical experience preferred

3 years QA experience preferred

CERTIFICATE/LICENSE                                                                        

N/A

PHYSICAL DEMANDS AND WORK ENVIRONMENT

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this position.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this position, the employee is regularly required to talk or hear. The employee frequently is required to use hands or finger, handle, or feel objects, tools, or controls. The employee is occasionally required to stand, walk, sit, reach with hands and arms, climb or balance, stoop, kneel, crouch, and / or crawl.

The employee must occasionally lift and/or move up to 15 pounds.  Specific vision abilities required by this position include close vision, distance vision, color vision, peripheral vision, and the ability to adjust focus.

The noise level in the work environment is usually moderate.

MACHINERY AND EQUIPMENT USED

Personal computer, multi-line telephone system, facsimile machine, and copier.

NOTE

This job description in no way states or implies that these are the only duties to be performed by the employee(s) incumbent in this position.  Employees will be required to follow any other job-related instructions and to perform any other job-related duties requested by any person authorized to give instructions or assignments.  All applicants made a conditional offer of employment must cooperate fully with background investigations.  All duties and responsibilities are essential functions and requirements and are subject to possible modification to reasonably accommodate individuals with disabilities.  To perform this job successfully, the incumbents will possess the skills aptitudes and abilities to perform each duty proficiently.  Some requirements may exclude individuals who pose a direct threat or significant risk to the health or safety of themselves or others. The requirements listed in this document are the minimum levels of knowledge, skills, or abilities.

This document does not create an employment contract, implied or otherwise, other than an “at will” relationship.

Reviewed with employee by:

Manager’s Name:________________________________________Date:_______________

Received and accepted by:

Employee’s Name: _______________________________________Date:_______________

NOTCH is an Equal Opportunity Employer, drug free workplace, and complies with ADA regulations as applicable.