POSITION SUMMARY
Under the general supervision of the Vice President and Chief Operations Officer (VP & COO), contributes to the company's mission and vision by supporting and coordinating clinical performance improvement activity and corporate compliance for employed physicians and staff. Manages the quality improvement activities of the health center. Works in collaboration with the VP & COO, QI Team, and Senior Management to identify and implement specific CQI initiatives. Ensures compliance with applicable accreditation, regulatory, and licensure standards. Ensures compliance with quality initiatives, including, but not limited to Patient Centered Medical Home, UDS, and HEDIS. Serves as Corporate Compliance Officer and Director of Risk Management.
WHY LRMC:
Little River Medical Center is a non-profit community health center within Horry County. At Little River Medical Center, we strive to offer exceptional health services and deliver quality, compassionate care to everyone. We provide a wide range of affordable health and support services for every family.
ESSENTIAL DUTIES AND RESPONSIBILITIES include the following.
- Directs efforts to ensure effective Quality Program and Performance Improvement implementation throughout all sites of Little River Medical Center.
- Provides guidance to employees/management in complying with the requirements and intentions of the program.
- Provides leadership to drive work for clinical improvement and service enhancement. Provides meaningful reports to the Quality Committee and senior management.
- Acts as a support for Quality Improvement and Patient Safety initiatives, as directed. Ensures that minutes are prepared and submitted from all meetings as directed.
- Acts as co-chair for the QI Committee.
- In coordination with the VP & COO, QI Team, Chief Medical Officer, and other senior management develops and implements programs, initiatives, and improvement strategies to ensure consistency in compliance with applicable laws, regulations, and other governmental requirements. Ensures that required state/federal reporting is completed in a timely manner.
- Monitors and communicates with VP & COO and senior leadership regarding quality improvement trends. Assists in preparations of metric reports and development of meaningful improvement plans.
- Oversees and monitors the peer review process.
- Facilitates effective communication with all staff, providers and senior management regarding key clinical performance improvement activities and initiatives.
- Oversees and monitors the development and implementation of LRMC’s Compliance Program.
- Identifies methods to reduce the LRMC’s vulnerability to fraud and abuse, such as conducting periodic audits, developing effective lines of communication on compliance issues, and preparing written practice standards and procedures.
- Develops and/or maintains the Compliance Program and compliance policies and procedures.
- Develops, coordinates, and participates in a training program that focuses on the components of the Compliance Program.
- Develops and/or maintains the written LRMC Code of Conduct and ensures staff and Board members receive the appropriate training/education.
- Receives reports or allegations of unethical or improper conduct or business practices, and responds to such reports, and implements and monitors appropriate corrective action and subsequent compliance.
- Reports information on the activities of the Compliance Program to the President & CEO and Board of Directors/QI Committee of the Board.
- Oversees all ongoing activities related to the development, implementation, and maintenance of the practice/organization's privacy policies in accordance with applicable federal and state laws.
- Collaborates with the information security officer to ensure alignment between security and privacy compliance programs including policies, practices, investigations, and acts as a liaison to the information systems department.
- Oversees initial and periodic information privacy risk assessment/analysis, mitigation, and remediation.
- Oversees initial and ongoing privacy training.
- Establishes and administers a process for investigating and acting on privacy and security complaints.
- Provides administrative oversight of OSHA compliance.
- Maintains awareness of laws and regulations as mandated or recommended by HRSA, OIG, CMS, and other agencies, keeping abreast of pending and or implemented changes. Develops communication tools to alert staff of changes.
- Maintains current competency with all current Quality Program initiatives including but not limited to, NCQA Patient Centered Medical Home, Uniform Data System (UDS) HEDIS and other governmental or payor programs.
- Provides education to providers and staff. Supports ongoing education related to Quality Program initiatives.
- Meets regularly with Site Supervisors/Managers and encourages shared learning.
- Participates in the orientation of new employees to Quality Initiatives.
- Oversees a corporate wide patient safety/risk management program; develops and maintains a written patient safety plan, and annual evaluation of the plan’s effectiveness and develops and maintains policies and procedures related to the patient safety program.
- Responsible for claims management for malpractice related claims.
- Reviews incident reports and conducts follow-up investigations as warranted.
- Collaborates with the applicable clinical and/or management staff in the investigation of clinical events including sentinel events, sentinel event near misses, and significant adverse events; leads and/or participates in the development of root cause analyses and corrective action plans.
- Reviews complaints, concerns, or questions relative to quality issues, and provide consultative leadership and support to sites and staff as appropriate.
- Oversees the patient satisfaction survey process.
- Maintains the strictest confidentiality in the areas of patient, employee, and physician relations.
- Oversees the Community Health Worker/Population Health Specialist Program and staff.
QUALIFICATIONS:
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. 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.
- Must be fully vaccinated against COVID-19.
EDUCATION and/or EXPERIENCE:
- Graduate of an accredited college or university nursing program. Work-related experience will be taken into consideration with a lower level degree.
- Master's Degree preferred.
- Minimum 3 years of related or management experience involving quality improvement, leadership, and healthcare quality practices, as well as associated regulatory rules and laws. At least one year must have been in capacity as direct supervisor of other professional level employees.
- Minimum 3 years direct experience in ambulatory care quality improvement preferred.
LRMC offers benefits such as:
- Medical, Vision & Dental insurance. Health Benefits start on the 1st of the month following the start date.
- Employer matched 403B Retirement Plan.
- Paid Vacation time, Sick time, & Holiday's. As well as paid qualifying Administrative Leave.
- Employer Paid Health Benefits: Life / AD&D Policies, Short/Long Term Disability, and an Employee Assistant Plan.