Job description

Position Description

Position Title: Compliance & Quality Manager

Department: Operations

Supervisor: Chief Operations Officer

Directs: Manages Compliance, Risk Management, Accreditation, Performance Improvement, Health Information Management

FLSA Status: Exempt

Salary Range:

Charles Drew Health Center, Inc. (CDHC) strives to pay its workforce at the midlevel or 50% of the industry and market baseline salary

range. For new hires, we offer pay at less than the 50% mark to allow for growth. CDHC offers a generous employee benefit package. The

combination of the pay and benefits results in a total compensation package in the 70% of the competitive salary range.

Charles Drew Health Center Expectations of all Employees:

• Adheres to all CDHC’s Policies and Procedures
• Conducts self in a manner that represents CDHC’s core values at all times
• Maintains a positive and respectful attitude with all work-related contacts
• Communicates regularly with her/his immediate supervisor about Departmental and CDHC concerns
• Consistently reports to work prepared to perform the duties of the position
• Meets productivity/performance standards and performs duties as workload necessitates

POSITION SUMMARY

The Compliance and Quality Manager is responsible for the development, implementation, oversight, and evaluation of all aspects of Charles

Drew Health Center (“Health Center’s”) compliance, risk management, accreditation, performance improvement and HIPAA programs.

POSITION-SPECIFIC COMPETENCIES/ESSENTIAL FUNCTIONS/DUTIES & RESPONSIBILITIES

Compliance Duties and Responsibilities

• Overseeing and monitoring the development and implementation of the Health Center’s Compliance and Risk Management

Programs through establishment of the annual compliance and Risk Management assessments and/or work plan(s).

• Monitor Compliance Hotline and ensure all calls are logged.
• Identifying methods, such as conducting periodic audits, developing effective lines of communication on compliance issues, and preparing written practice standards and procedures to reduce the Health Center’s vulnerability and risk.
• Co-Chair the Joint Commission Committee and serve as the Joint Commission Accreditation Administrator; including co-chairing

TJC sub-committees

• Oversee Performance Improvement Committees; ensuring administrative, medical, dental, behavioral health and pharmacy key performance indicators support the safe and effective care of patients, as well is continually improve the patient experience.
• Analyzing, monitoring, and actively making, and recommending, revisions of policies and procedures with departmental leadership;

Keep a focus on changes in HRSA, TJC and OSHA compliance, or changes in the law and/or in the standards and procedures of government and private payer health plans.

• Administrator for Learning Management System
• Developing, coordinating, and participating in training programs that focuses on the components of the Compliance Program and seeks to ensure that all individuals affiliated with the Health Center (i.e., employees, contractors, vendors, agents, and volunteers) are knowledgeable of, and comply with, pertinent policies and procedures
• Receive reports or allegations of unethical or improper conduct or business practices, and responding to such reports, including by conducting investigations and/or in coordination with Chief Executive Officer, or by delegating the responsibility for conducting an investigation to other staff or to a qualified third party, and implementing and monitoring appropriate corrective action and subsequent compliance
• Health Information Management oversight
• Report information on the activities, outputs, and impact of work in a monthly operations report to COO
• Monitor, log, and analyze patient experience surveys, incident reports, and sentinel events. Report trends, and results to the Total

Quality Management Committee, Executive Leadership, department staff, and individual providers, on a monthly basis or as appropriate. Prioritize issues in risk assessment based on level of organization exposure and work collaboratively with departmental and executive leadership to review analysis and address areas for improvement.

• Participate in Infection Control Committee and related activities
• Responsible for monitoring effective infection control measures where appropriate
• Participate in education strategies related to infection prevention for staff and organization
• Responsible for monitoring compliance of personnel regarding local, state and federal rules and regulations for risk management including the prevention and risk of infections in ambulatory care.
• Other duties as assigned.

KEY ATTRIBUTES:

• A philosophy of collaboration and teamwork.
• Clinical credibility with physicians and support staff.
• A mission-driven individual who can embrace and commit to Mission and Core Values; articulate about stewardship.
• A philosophy of management by being present, actively engaged and being a servant leaders.
• A self-starter, results-oriented personality.
• High tolerance for complex, ambiguous, and ever-shifting environments, including a matrix management structure.
• Excellent interpersonal and communication skills, with the ability to build consensus; noticeable skills in engaging Providers, support staff and patients.
• The ability to relate well to a wide variety of individuals. Comfortable working in groups, forming teams and understanding how to create change through influence and not through direct authority.
• Has the attitude of prioritization not scarcity.
• The ability to hear, to understand, to reflect, and to mediate on issues.
• An appreciation of the importance of the clinical team, and what nursing, patient care departments and operations brings to the patient care endeavor, and the strength of that clinical partnership.
• A sense of humor and the ability to generate optimism in fellow team members.

POSITION REQUIREMENTS

• Bachelor’s Degree required in business, public health, health or related field and\or at least 4 years of related management experience demonstrating progression in increased work responsibilities.
• Demonstrated knowledge of and competency with regulatory compliance in the healthcare industry required and experience with Federally Qualified Health Center required.
• Demonstrated mastery of critical thinking, analytics, and problem solving skills required.
• Demonstrated ability to interact and communicate effectively with individuals at various levels both inside and outside of the organization, often in sensitive situations.
• Proficiency with Microsoft Office – particularly Excel and PowerPoint; familiarity with an Electronic Practice Management (EPM) and/ or Electronic Health Record (EHR).
• Knowledge and experience in areas of patient care practices with disinfection/sterilization, patient education, infection prevention preferred. A minimum of 3-4 CEUs completed annually related to infection control required.
• Hours of Work: Expect to work 40 hour a week minimum.
• Travel: Some travel required.
• Exposure: The exposure characteristics described here are representative of those an employee encounters while performing the essential functions of this position. For example, while performing the essential functions of this job, the employee is rarely exposed to fumes or airborne particles and toxic or caustic chemicals. Additionally, the employee may occasionally be exposed to bloodborne and other hazardous chemicals. Finally, the noise level in the work environment is rarely loud. In all cases personal protective equipment will be provided to the employee in combination with adequate ventilation and other engineering controls to minimize the risk of exposure or other hazardous occurrence.
• Physical: Reasonable accommodation may be made to enable individuals with special challenges to perform these essential functions.

Job Type: Full-time

Pay: $65,000.00 - $80,000.00 per year

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Schedule:

• Monday to Friday

Ability to commute/relocate:

• Omaha, NE 68111: Reliably commute or planning to relocate before starting work (Required)

Experience:

• ISO 9001: 1 year (Preferred)

Work Location: One location

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