Director, Quality and Regulatory

Company: Alive Hospice, Inc.
Location: Nashville
Posted on: April 18, 2024

Job Description:

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Description
SUMMARYThe Director, Quality and Standards provides direction and oversight of the organizations Quality Program and Regulatory Standards for Alive Hospice. The Director, Quality and Standards is responsible for collaboration with all agency departments to drive the organizations compliance with regulatory and accreditation standards and facilitates process improvement through appropriate data collection, analysis, sharing and application; along with leading process improvement efforts to ensure compliance with agency, local, state and national quality initiatives.
For purposes of clarification, Regulatory Compliance is defined as all health care regulatory compliance including OIG, CMS, TJC, and HIPAA and other regulations that directly or indirectly impact the operations of Alive Hospice.
QUALITY ESSENTIAL DUTIES AND RESPONSIBILITIES

• Collaborate with the VP of Operational Improvement to achieve department and organization goals and outcomes
• Collaborate with the Director of IT for optimization of Agency information systems to support and improve processes
• Facilitation of Root Cause Analysis (RCA), Failure Mode Effects Analysis (FMEA), and Performance Improvement efforts
• Regularly review the Quality Program and recommends appropriate revisions and modifications to the VP of Operational Improvement
• Data gathering to identify opportunities for performance improvement
• Collaboration with all stake holders to ensure reporting needs are identified and met
• Analytic support for departments across the organization
• CMS quality monitoring and reporting
• Present periodic and annual reports on the Quality Program
• Develop, coordinate, and/or oversee internal and external audit procedures for the purpose of monitoring and detecting performance improvement opportunities
• Recommend solutions, and follow up to ensure that the recommendations have been implemented and are effective
• Service recovery monitoring and follow up
• Collaborate with Healthcarefirst for collection and reporting of family satisfaction surveys
• Electronic Medical Record (EMR) enhancement support
• Collaborate with Director of IT to design and/or refine data tools and systems to streamline agency processes
  REGULATORY ESSENTIAL DUTIES AND RESPONSIBILITIES
  • Monitor state, federal and JCAHO Regulatory Compliance to help the organization prevent and/or detect violation of law, regulations, policies, or the Code of Conduct.
  • Coordinate resources to ensure the ongoing survey readiness and adherence to state, federal an accreditation standards
  • Develop education programs for all employees, agents, affiliated providers, or others working with the organization
  • Oversee follow-up and, as applicable, resolution to survey deficiencies and self-assessments
  • Facilitate plan of correction activities and follow up.
  • Develop productive and collaborative working relationships with all levels of management.
  • Work with Department Leadership to provide adequate information to employees of to ensure that they have the requisite information and knowledge of regulatory issues and requirements to carry out their responsibilities in a lawful and ethical manner
  • Ensure and understand the company's commitment to comply with all laws, regulations, company policies, and ethical requirements applicable to the conduct of the business
  • Assess the need for additional training and education and develop appropriate regulatory compliance tools and resources.
  • Carry out all duties and responsibilities as assigned by the Quality and Compliance Oversight Committee and/or under the Corporate Integrity Program.
  • Perform other duties as assigned
    SUPERVISORY RESPONSIBILITIESDirectly supervises Infection Control Nurse. Carries out supervisory responsibilities in accordance with the organization's policies and applicable laws. Responsibilities include interviewing, hiring, and training employees; planning, assigning, and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and resolving problems.
    LANGUAGE SKILLSAbility to read, analyze, and interpret the most complex documents. Ability to respond effectively to the most sensitive inquiries or complaints. Ability to write speeches and articles using original or innovative techniques or style. Ability to make effective and persuasive speeches and presentations on controversial or complex topics to top management, public groups, and/or boards of directors.
    MATHEMATICAL SKILLSAbility to apply mathematical operations to such tasks as frequency distribution, determination of test reliability and validity, analysis of variance, correlation techniques, sampling theory, and factor analysis.
    REASONING ABILITYAbility to apply principles of logical or scientific thinking to a wide range of intellectual and practical problems. Ability to deal with nonverbal symbolism (formulas, scientific equations, graphs, etc.,) in its most difficult phases. Ability to deal with a variety of abstract and concrete variables.
    OTHER QUALIFICATIONSCommunication and Relationship Skills: Exemplifies high level of written oral and listening communication skills, always respecting patient confidentiality.Agency Policy and Philosophy: Communicates and supports agency mission and values in all professional interactions.Continuing Education: Seeks to improve knowledge and skills relative to performance of job and personal growth.Quality and Performance Improvement: Participates in new and continuing programs designed to monitor and improve quality and performance relevant to the mission and philosophy of Alive Hospice, Inc.Teamwork: Functions consistently and collaboratively as an integral part of Patient Care Team and other teams (committees, etc.) bringing experience and education to contribute to optimal team functions and outcomes.Ethics: Demonstrates a high level of work, personal and professional ethics.
    CERTIFICATES, LICENSES, REGISTRATIONSIf required to drive to carry out the duties of this position: current drivers license and automobile insurance as required by Tennessee State Law.
    PHYSICAL DEMANDSThe physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.While performing the duties of this job, the employee is regularly required to sit and talk or hear. The employee frequently is required to use hands to finger, handle, or feel and reach with hands and arms. The employee is occasionally required to stand and occasionally lift and/or move up to 25 pounds. Specific vision abilities by this job include close vision, and ability to adjust focus.
    WORK ENVIRONMENTThe work environment characteristics described here 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. While performing the duties of this job, the employee is occasionally exposed to use of an automobile. The noise level in the work environment is usually moderate. Work is generally performed in a general office setting.
    
    Requirements
    CONTINUING EDUCATIONThe agency requires this position to complete 15 hours of continuing education per year covering topics that will contribute to improvements in carrying out the above responsibilities. Regulatory agencies may require some disciplines to have additional hours in order to be licensed or certified
    QUALIFICATIONSTo perform this job successfully, an individual must be able to perform each essential duty satisfactorily, including meeting the required competencies. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
    EDUCATION and/or EXPERIENCEBachelors degree, Masters preferred; CPHQ (Certified Professional in Healthcare Quality) preferred; 3-5 years Clinical Informatics background; demonstrated professional experience working with clinical records, documentation, billing and auditing.
    
    
    
    
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Keywords: Alive Hospice, Inc., Nashville , Director, Quality and Regulatory, Executive , Nashville, Tennessee