Compliance, Quality, And Education Director

HOSPICE OF THE VALLEY

JOB DESCRIPTION

COMPLIANCE, QUALITY & EDUCATION DIRECTOR

REPORTS TO: CEO

JOB GOAL:The Director of Compliance, Quality and Education has accountabilities for the monitoring, implementation and evaluation of process and programs to meet all regulatory, accreditation and standards of practice. This position assures the agency compliance with State and Federal regulations, standards for hospice licensing and certification channels, investigations and corrective actions, as well as Hospice of the Valley’s Policies and Procedures (P&Ps).

In addition, this role is responsible for the management of the American Health Information (AHIMA) department and /or National alliance of Medical Auditing Specialists (NAMAS) and payer coverage guidelines and serves as the organization’s Privacy Officer.

MINIMUM QUALIFICATIONS:

Bachelor’s degree in nursing, healthcare management or related field required; and

Minimum of three years in hospice experience is required. Must be knowledgeable, at minimum about Hospice Medicare Conditions of Participation and Alabama Hospice Alabama Hospice Quality/Compliance management is preferred; and

Certification in Health Care Compliance (CHC) required or must be obtained within 12 months of hire; and

Be licensed by the Alabama State Board of Nursing to practice as a registered nurse in the State of Alabama; and

Must successfully complete the pre-employment physical, and submit to immunizations, required for this position, and periodic skin tests or chest x-rays at Agency expense; and

Possess a valid Alabama Driver’s License; and

Possess current liability car insurance.

Possess and maintain a current CPR Certification.

ADDITIONAL DESIRABLE QUALIFICATIONS:

1.Proficient in Excel, Word, and PowerPoint

2.Strong interpersonal skills.

3.Must be detailed oriented with demonstrated ability to work independently and organize workload with accuracy.

4.Must have excellent verbal and written English communication skills.

5.Knowledge of appropriate communication skills to include ability to communicate with both internal and external customers and effectively present information one-on-one or in group settings.

6.Ability to problem-solve involving many variables in both standard and exceptional situations.

ESSENTIAL FUNCTIONS

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1.Regularly monitors changes to the regulatory landscape to ensure compliance with applicable state and federal laws, regulations, and mandates.

2.Develops, initiates, maintains, and revises policies and procedures for the general operation of the Compliance program and its related activities to prevent illegal, unethical, or improper conduct.

3.Acts as a key resource to managers and provides guidance in support of the organization’s strategy for complying with all regulatory requirements related to clinical and non-clinical activities.

4.Maintains extensive knowledge and experience pertaining to regulatory compliance.

5.Promotes compliance and works with leadership throughout the organization to strategically improve and integrate regulatory compliance into processes, systems, and employee awareness.

6.Designs, develops, implements, and evaluates compliance training for all levels of staff to support and awareness and understanding of regulatory requirements.

7.Oversees the development of audit, monitoring, and assessment tools and evaluation processes.

8.In conjunction with the CEO, Patient Services Director, oversees external regulatoryrequest.

9.Establishes and implements efficient and effective HIM policies, procedures, and processes, provides quality assurance for department activities conducted by the HIM department.

10.Responsible for the performance of the Compliance, Quality and HIM department. Develops and manages the department budgets. Manages the recruitment and training of departmental staff and manages their performance through the performance appraisal process. Plans and organizes the work of the departments and assigns resources as needed.

11.Serves as the organization’s Privacy Officer and oversees all ongoing activities related to the development, implementation, maintenance of, and adherence to the organizations policies and procedures covering the privacy of, and access to patient health information in compliance with federal and state laws and the healthcare organization’s information privacy practices including HIPAA.

12.Exhibits and models appropriate interpersonal skills and leadership qualities necessary to implement successful management philosophy and training.

13.Provides oversight for the Agency’s Quality Assessment and Performance Improvement efforts (QAPI).

14.Directs, develops, and oversees all activities related to staff development, including individual/group training, standardized orientation program, and ongoing staff continuing educational and in-service requirement. Ensures the development of clinical expertise for all specialty programs.

15.Plans, coordinates, and teaches continuing education and in-service education.

16.Responds to the needs of the Agency and the development by performing other duties as assigned.

17.Institutes and ensures an effective compliance communication program for the organization, including promoting the use of the Compliance Hotline and awareness of the organization’s Code of Conduct.

18.Coordinates investigations into non-compliance, establishes a retribution-free system for the Agency.