Quality Director and Compliance Officer (FT)

Ohio Valley Surgical Hospital•Springfield, OH

24d

About The Position

Quality Director and Compliance Officer (Full-Time) We look forward to finding new team members with the commitment and talent to help us provide excellent care for our patients as the best quality, value and choice in the region. At Ohio Valley Surgical Hospital, our mission is to Elevate the Standard of Health Care in Our Community , and our core values guide the way we fulfill our mission. In service to each patient, we value quality, compassion, and care you can trust. The Quality Director and Compliance Officer is a registered nurse. The Compliance Officer ensures compliance with customer and regulatory requirements for quality, safety, risk, and reliability. Assist and monitor collection, investigation, analysis and reporting of infection control, quality improvement, patient experience, orthopedic spine service line, and risk management information. In addition, oversees education department.

Requirements

Current license in the state as a Registered Nurse.
Good communication skills to collaborate with appropriate individuals and organizations.
Efficient with Microsoft office

Nice To Haves

MSN preferred or obtain within 3 years of hire.
Certified in Healthcare Compliance preferred at time of hire or obtained within 1 year of hire.
Experience working with legal professionals preferred.

Responsibilities

Under the direction of the Quality Medical Director and Chief Nursing Officer, the Quality Director develops and implements a quality and performance improvement (PI) plan and processes.
Coordinates quality improvement activities and data collection according to the PI plan.
Gathers data, evaluates data, creates reports, promotes action plans, reevaluates processes as needed, reports, and provides a monthly summary/dashboard.
Oversee Quality Improvement, Compliance/Ethics, Infection Control, Risk Management, Education, Employee Health, and Hospital Service Line leaders.
Assists with the review, development, and implementation of policies, procedures, and plans to proactively manage risk including HIPAA, foster a culture of safety, and prevent illegal, unethical, or improper conduct.
Ensures reportable events are reported to regulatory agencies as directed.
Collects, investigates, and evaluates risk/compliance related data/concerns and reports to appropriate leadership and/or regulatory agency.
Oversee the Compliance hotline and ensure follow-up with appropriate leaders or regulatory agencies on any reported HIPAA or other compliance concern.
Completes the compliance plan/dashboard and maintains the core elements (including written policies and procedures, training and education, compliance committee, hotline, internal monitoring and auditing, enforcing standards, response and corrective action and consistent enforcement and disciplinary guidelines) required for an effective corporate compliance program.
Review compliance issues, trends, or concerns and act as an independent review and evaluation body to ensure that compliance Issues/concerns within the organization are being appropriately evaluated, investigated, and resolved.
Provides guidance for the Board and executive management team on matters relating to compliance.
Participates in the investigation and analysis of root causes, patterns or trends that could result in compensatory or sentinel events.
Assists to identify and implement corrective action based upon trends, evidenced based practice, and/or root cause analysis where appropriate.
Actively participates in facility committees related to infection control, risk management, service lines, emergency management, pharmacy and therapeutics, and safety.
Oversee the compliance/ethics and performance improvement committees.
Oversee hospital ongoing readiness for regulatory compliance.
Monitors, follows-ups, tracks, and reports patient grievances.
Oversees service line accreditation programs for continued compliance.
Assists leaders with consults to legal counsel as needed to resolve difficult compliance issues, and actual or potential hospital professional liability (e.g. medical malpractice, litigation matters, professional liability, general liability, workers’ compensation, motor – vehicle liability, property, directors/officers, fiduciary liability, ERISA, OSHA, HIPAA, TJC, Medicare and Medicaid regulations, health-care regulations, state reporting requirements, patient safety, and patient consent forms.
Develop education about potential risks, liabilities, compliance, and the Code of Conduct.
Collaborates with other departments (e.g., Finance, Revenue Cycle, Human Resources, ancillary/nursing departments, etc.) to direct compliance issues to appropriate existing channels for investigation and resolution.
Oversee legal claims processing by reporting, investigating, and providing information to legal counsel.
Performs other duties as assigned or required.