Are you a Quality/Regulatory Compliance professional who desires to work in a capacity in which your efforts directly impact clinicians, patients and their loved ones?
If you are eager to use your talents and skill set in a way that truly makes a difference in the Middle TN healthcare market, we can't wait to talk with you!
The Quality and Regulatory Manager provides direction and oversight of the organizations Quality Improvement and Performance Improvement plan (QAPI) and Regulatory Standards for Alive Hospice. The Quality and Regulatory Manager 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 Director of Quality and Compliance to achieve department and organization goals and outcomes
Collaborate with the VP of Information Technology and Security 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 QAPI program and recommends appropriate revisions and modifications to the Director of Quality and Compliance
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 QAPI 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 VP of Information Technology and Security to design and/or refine data tools and systems to streamline agency processes
REGULATORY ESSENTIAL DUTIES AND RESPONSIBILITIES
Monitor state, federal and The Joint Commission (TJC) 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 standard
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 board appointed Quality and Compliance Committee and/or under the Corporate Integrity Program.
Perform other duties as assigned
Direct oversight of the Infection Prevention program. 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
Bachelor’s degree, hospice experience strongly preferred. RN license is required. CPHQ (Certified Professional in Healthcare Quality) preferred; 3-5 years Clinical Informatics background; demonstrated professional experience working with clinical records, documentation, billing and auditing.
Telecommuting is allowed.
Internal Number: 2021-01
About Alive Hospice
We provide loving care to people with life-threatening illnesses, support to their families, and service to the community in a spirit of enriching lives.
To be recognized as expert providers of hospice care, palliative care, management of advanced disease and grief support and to be the agency of choice for the provision of these services.
To be recognized as innovators and leaders in all aspects of end of life resources.
To influence the perceptions within the community and among medical professionals so that the end of life is accepted as a meaningful component of the human experience.
We believe death to be a natural part of life’s journey.
We believe in honesty and integrity in all we say and do.
We believe in compassion to those we serve and to each other.
We believe in respect and dignity for all.
We value competent knowledgeable staff motivated to achieve personal and professional growth.
We believe in accountability to society, our community and each other.
We believe in responsible stewardship of the resources to which we have been entrusted.
We believe in the continuous pursuit of organizational excellence.
We believe in teamwork to achieve our vision, mission and to support our values.