DescriptionPurpose:
Responsible for leading an effective quality management system organization-wide, leading and nurturing the quality department, and serving as a key leader for compliance management.
Responsibilities:
- Provides leadership, resources and support services for quality department functions including compliance, continuous quality improvement, emergency preparedness program administration, forms management, credentialing, contract management, policy management, and facilitation of the ethics consultation service.
- Ensures services are provided in compliance with organizational quality assurance standards, regulatory mandates, accrediting bodies, grant contracts, and federal, state, and local laws.
- Oversees policy management system, ensuring ongoing collaboration with leaders and effective processes for timely review, revision and archiving of EveryStep policies and procedures.
- Oversees contract management system, ensuring ongoing collaboration with leaders and effective processes for timely review, revision and archiving of EveryStep contracts.
- Maintains current key planning documents through periodic assessment and evaluation, updating as needed. Distributes updated documents to leadership and makes them available to all staff. Documents include, but are not limited to, Emergency Preparedness Plan, Compliance Plan, Exposure Control Plan, COVID-19 Plan, and Respiratory Protection Program.
- Interprets and distributes information on regulatory matters, risk assessments, compliance assessments, quality gaps and performance improvement opportunities. Serves as a resource for regulatory research and interpretation.
- Maintains quarterly compliance activities report in collaboration with the VP and Chief of Compliance.
- Supervises credentialing services and collaborates with the Revenue Cycle Management Director on management of credentialing.
- Contributes to organization planning within scope of the quality department's responsibilities, resources and support.
- Monitors and reports results of the compliance/ethics efforts of the organization and provides guidance to leadership.
- Oversees management of the compliance hotline and whistleblower reporting.
- Participates as needed in investigations of situations presenting compliance and/or safety risk. Collaborates with HR Director when investigations involve employees.
- Stays informed of changes in the fields of public health, home health, and hospice and shares information with appropriate EveryStep staff.
Quality Management
- Reviews programs against state, federal and local regulations and organization's by-laws.
- Assesses care and safety processes, including but not limited to adverse events and infection prevention and control. Focuses primarily on high-risk, high-volume, or problem prone areas and shows consideration for the incidence, prevalence, and severity of problems in those areas.
- Analyzes data using statistical tools and benchmarks, evaluates trends, and identifies opportunities for improvement of care and services, including those provided through contractual arrangement.
- Communicates findings using accurate and effective reporting tools and dashboards. Develops and customizes reporting tools and dashboards as needed.
- Collaborates with team(s) to develop effective data-driven quality initiatives and performance improvement projects. Responsible for leading QAPI for supporting clinical services regulations in home care and hospice.
- Collaborates with clinical services leadership team for CHAP survey preparation and participates as needed during onsite surveys for providing resource and support.
- Identifies performance measures and metrics to monitor progress and success. Identifies other helpful resources and tools to support improvement efforts. Serves as a resource for hospice and home care policy development and interpretation.
- Identifies potential barriers to success of quality initiatives and performance improvement projects as well as strategies to overcome those barriers, including recommendations for staff education and training. Delivers staff education and training as needed.
- Prepares written action plans for quality initiatives and performance improvement projects and clearly communicates objectives to all stakeholders.
- Encourages staff member involvement and engagement in quality initiatives and performance improvement projects and assists in leading staff through change in a positive and meaningful way.
- Attends Compliance/Quality Committee board meetings and facilitates a discussion on the progress of quality initiatives and performance improvement projects.
Leadership Standards:
- Complies with all established policies, procedures and guidelines, including state and federal regulations, to assure safe practices and quality services.
- Ensures stewardship of financial resources.
- Represents the organization in a professional manner and promotes a culture of integrity, respect, compassion, excellence and teamwork.
- Establishes and maintains collaborative professional relationships within the organization and community.
- Engages in opportunities for professional and leadership development.
- Demonstrates ability to handle multiple priorities in an organized manner, make timely decisions, and exercise sound independent judgment.
- Demonstrates commitment to continuous quality/performance improvement through development, implementation, monitoring and reporting of the balanced scorecard.
- Recruits, hires and retains talented, qualified staff who share the organization's values.
- Clearly communicates roles, responsibilities, performance standards and expectations to staff.
- Ensures staff have the necessary training and skills needed to be effective team members.
- Regularly checks in with staff to provide constructive feedback and discuss progress towards goals, offering coaching, support or guidance as needed.
- Clearly communicates organization objectives to staff, preserving confidentiality as needed.
- Conducts timely performance reviews according to organization policy.
- Addresses performance or conduct issues immediately and provides effective counseling and corrective action as needed.
- Recognizes and celebrates staff accomplishments and exceptional performance and services.
Qualifications:
- Bachelor's Degree required in Business Administration, Law, Compliance, Public Health Administration or related field; Master's degree in related field strongly preferred
- At least 5 years or more of progressive experience in public health and/or home health care, including at least 3 years in management
- Experience with contract management
- Experience with policy and procedure management
- Ability to plan, organize, prioritize, make timely decisions and exercise sound independent judgment
- Ability to apply financial, regulatory, and management information systems technology to clinical practice
- Ability to meet and work effectively with clinical personnel, public health officers and officials, lay boards, medical staffs, community agencies and the public
- Ability to demonstrate self-direction, time management and problem-solving skills
- Demonstrated organization, facilitation, communication and presentation skills
- Ability to work effectively with diverse populations
- Ability to remain current with changes in legislation and accreditation standards that affect health information and privacy
- Knowledge of quality improvement techniques and practices
- Ability to delegate responsibilities appropriately
- Strong keyboarding and computer skills and ability to learn work-related software
- Must have valid driver's license, auto liability insurance and reliable transportation if driving is required
- Successful completion of pre-employment physical, drug screen, 2-step TB test and background check
Working Conditions:
- Physical requirements: Sedentary work exerting up to 10 pounds occasionally, and/or a small amount of force frequently to move objects, including the human body
- Physical activities: Reaching, Standing, Walking, Pushing, Pulling, Lifting, Talking, Fingering (picking, pinching, typing, etc.) Hearing, Grasping (applying pressure with fingers and palm), Repetitive motions, Feeling (perceiving size, shape, texture, temperature by touching), Visual acuity (field of vision for analyzing data, viewing computer, using measurement devices, operating machines, determining accuracy or neatness, and/or making general observations)
- Environment: Work is primarily performed in a climate controlled environment with minimal safety/health hazard potential
- Time: Ability to be flexible with a varying schedule and programmatic requirements
- Travel: Required between locations
These characteristics are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Note: This job description is not intended to be all-inclusive. You may be required to perform other duties to meet the on-going needs of the organization.
