JOB TITLE: Quality Management/Compliance Director
DEPARTMENT: Quality Management/Compliance
REPORTS TO: Chief Medical Officer
*Work Location: This position is
onsite only. Remote work is
not available for this role. The successful candidate must be able to work onsite as required by the position's schedule.
JOB SUMMARYResponsible for the leadership and integration of the Quality Management functions that include Performance Improvement, Risk Management, Patient Safety, Infection Control, Data Chart Abstraction, and Survey Readiness and Preparation. Responsible for the coordination of the regulatory surveys for the organization. This position is also responsible for overseeing Case Management and Utilization Review functions for the hospital.
The Compliance Director oversees the Compliance Program and provides leadership, direction and accountability related to compliance matters within the organization. Assists the Board of Trustees, Senior Leadership, employees, medical staff and workforce to comply with federal, state and local statutes, regulations and ordinances. This position ensures that the organization's policies and procedures are being followed and that the behavior in the organization is consistent with the Compliance Program's Code of Conduct.
The Compliance Director exists 1) as a channel of communication to receive and direct compliance issues to appropriate departments for investigation and resolution and 2) as a final internal resource with which concerned parties may communicate after other formal channels and resources have been exhausted.
QUALITY/CASE MANAGEMENT & INFECTIONJOB REQUIREMENTSRegistered Nurse, BSN or bachelor's degree in a related field required. Master's degree preferred.
EXPERIENCEA minimum of five (5) years of professional health care experience in an acute setting or equivalent combination of education and experience. Must have a working knowledge of current hospital concepts in Performance Improvement and regulatory surveys. Prefer minimum 2 years of experience in a Quality Director role. Must demonstrate skill preparing and maintaining records and writing reports. Must exhibit a high degree of skill in organization, time management, and the ability to efficiently operate within budgetary constraints.
SKILLS- Maintains a high degree of credibility, independence, integrity, and trust.
- Demonstrates sound business judgment and is supportive of the hospital mission and objectives.
- Commands respect from senior management team, the Medical Staff and Board of Trustees.
- Must possess a high degree of confidentiality in all matters with the ability to manage sensitive and confidential situations with tact, professionalism, and diplomacy.
- Strives to develop partnerships, teamwork and good working relationships maintaining an open management style.
- Exhibits analytical skills and an understanding of operational processes to drive organizational improvement.
- Strong communication and leadership skills are essential.
- Able to operate successfully in a constantly changing, fast-paced environment.
- Demonstrated initiative, self-motivation, practical learning skills, enthusiasm, and an ability to complete multiple tasks in a timely and accurate manner.
- Must be able to interact effectively with a wide variety of people.
- Must be able to write policies and procedures.
- Strong computer and keyboarding skills.
- Must be proficient in the use of Microsoft Office Suite products knowledge including Word, Excel and Outlook.
- Ability to learn new computer software applications.
- Knowledge of insurance and malpractice liability.
- Knowledge of local, state and federal regulations.
- Knowledge of principles and practices related to performance improvement and risk management.
- Ability to collect, organize and evaluate statistical data and format information to present to others.
- Ability to plan, organize and implement new programs and processes for Performance Improvement, Risk Management, Infection Prevention & Control and Case Management/Utilization Review.
REQUIRED CERTIFICATIONS- Must obtain the Certified Professional in Healthcare Quality (CPHQ) designation within one year of hire.
- Other relevant certifications or training preferred: Certified Professional in Patient Safety (CPPS), Certified Professional in Health Care Risk Management (CPHRM), Institute for Healthcare Improvement training, TeamSTEPPS Master training, Lean, Six Sigma.
COMPLIANCEJOB REQUIREMENTSBachelor's degree required. Master's degree preferred.
EXPERIENCEAt least five years of experience in healthcare OR equivalent combination of education and experience. Specific experience with regulatory issues is desirable.
SKILLS- Must possess a high degree of confidentiality in all matters with the ability to manage sensitive and confidential situations with tact, professionalism, and diplomacy.
- Maintains a high degree of credibility, independence, integrity, and trust.
- Demonstrates sound business judgment and is supportive of the hospital mission and objectives.
- Commands respect of the senior management team, board level committees and other members of the compliance team.
- Strives to develop partnerships, teamwork and good working relationships maintaining an open management style.
- Exhibits analytical skills and an understanding of operational processes to drive organizational improvement.
- Understands the complexities of a large organization. Involves others appropriately in consultations and decisions.
- Understands the legal and regulatory framework of the entity.
- Exhibits analytical skills and an understanding of operational processes and technology concepts.
- Maintains strong writing skills required to write and edit policies and procedures, memorandums and program reports.
- Exhibits good presentation skills with large and small audiences.
- Able to operate successfully in a constantly changing, fast-paced environment. Demonstrated initiative, self-motivation, practical learning skills, enthusiasm, and an ability to complete multiple tasks in a timely and accurate manner.
- Strong communication and leadership skills are essential.
- Demonstrated initiative, self-motivation, practical learning skills, enthusiasm, and an ability to complete multiple tasks in a timely and accurate manner.
- Must be able to interact effectively with a wide variety of people.
- Must be able to write policies and procedures.
- Strong computer and keyboarding skills.
- Must be proficient in the use of Microsoft Office Suite products knowledge including Word, Excel and Outlook.
- Ability to learn new computer software applications.
REQUIRED CERTIFICATIONSMust possess a nationally recognized certification in healthcare compliance such as healthcare compliance (CHC), healthcare research compliance (CHRC), healthcare privacy compliance (CHPC), or a similar nationally recognized credential with transferrable competencies at hire or within two (2) years of hire.
