Description
The position leads the organization-wide strategy for clinical quality, patient safety, enterprise risk management, and regulatory compliance. This position partners with executive leadership and clinical staff to build a culture of continuous improvement, ensure survey readiness, mitigate legal and operational risks, and maintain strict adherence to federal, state, and accreditation standards.
Duties and Responsibilities:
Utilization Review
Concurrently reviews all Acute and Observation admissions daily for medical necessity and provides documentation in the record for physicians to review. Performs continuing review on medical records and identification and need of on-going hospitalization.
Maintains compliancy with regulation changes affecting utilization management.
Contacts and assists physicians to further evaluate the admission and continued stay when cases fail to meet the criteria.
Coordinates with Discharge Planner regarding the level of nursing care and when a patient will need discharge planning assistance.
Acts as a resource to physicians and hospital staff in areas of Utilization Management.
Quality Improvement & Performance Management
Oversee the Quality Assurance and Performance Improvement (QAPI) program, establish metrics, dashboards, and scorecards to track clinical and operational outcomes.
Track Key Performance Indicators and create reports or dashboards for executive leaders.
Run regular audits of internal records, systems, and clinical or operational procedures.
Use data findings to design and implement plans to improve daily operations efficiency, while maintaining patient safety and outcomes)
Assists departments in developing and maintaining QAPI plans and monitors compliance. Reports compliance of this task to committee monthly.
Organizes and promotes webinar trainings/seminars to hospital employees.
Risk Management
Oversee the incident reporting system for accidents, errors, or complaints.
Facilitate Root Cause Analysis reviews for adverse events, near-misses, and patient grievances.
Work with Department Heads to create corrective action plans.
Corporate Compliance
Oversee the Corporate Compliance Program, ensuring adherence to HIPAA, HITECH, CMS guidelines, OSHA, and state regulations.
Maintain continuous survey readiness for accrediting bodies and manage external regulatory inspections.
Manage confidential reporting or whistleblower channels for ethical violations.
Leads corporate compliance meetings and maintain minutes from the meetings.
Direct the annual review, development, and implementation of organizational policies, procedures, and compliance training campaigns for staff and medical personnel.
Requirements
Experience
Minimum of 3 to 5 years of progressively responsible experience in healthcare quality improvement, risk management, or regulatory compliance. Registered Nurse (RN) or clinical background preferred, but strong administrative compliance experience accepted.
Education
Bachelor's degree in Healthcare Administration, Nursing, Public Health, or a related field required; Master's degree preferred.
Professional certifications preferred: Certified Professional in Healthcare Quality (CPHQ); Certified in Healthcare Compliance (CHC / CCEP); Designation through the American Society for Healthcare Risk Management (ASHRM)
