Heartland Health Services- Central Illinois
Director of Quality and Compliance
Heartland Health Services- Central Illinois, Greendale, Wisconsin, United States, 53129
Heartland Health Services- Central Illinois
Heartland Health Services provides high quality health care services to all. Regular Office Hours: Monday- Friday: 8:00am- 4:30pm. Walk-ins welcome. Health Benefits Start Day 1 of Employment - No Waiting Position Summary The Director of Quality and Compliance (DQCO) provides clinical and administrative services and demonstrates the knowledge and skills necessary to provide quality assurance that is appropriate to the ages of the patients served, in accordance with Heartland Health Services’ (HHS) mission and strategic goals, federal and state laws and regulations, performance and outcome objectives, and accreditation standards. Essential Functions Responsible for providing consultation and education related to clinical quality and patient safety, accreditation, FTCA, PCMH, regulatory and licensing, risk management, and infection prevention and control; contributing to the evaluation, design, and development of evidence-based guidelines, principles, and/or programs related to area of work as well as facilitating implementation efforts to reduce variation in clinical practice and optimize patient outcomes; assisting with the collection, analysis, report development, and presentation of clinical data for a variety of users including for state, federal, and local agencies; monitoring, reporting, and developing mitigation plans for all occurrences which may lead to liability, fraud, etc. for HHS. Listens to, seeks, and addresses performance feedback; proactively provides actionable feedback to leaders verbally and in writing. Adapts to and learns from change, challenges, and feedback; demonstrates flexibility in approaches to work; champions change and helps others adapt to new tasks and processes. Facilitates team collaboration to support the strategic priorities of HHS. Develops and utilizes quality improvement performance metrics to establish improvement success; collaborates with multiple stakeholders, often with competing/conflicting objectives, to ensure development of cohesive and reachable metrics are practical and approved; and facilitates the collection of metric data from workflows and projects by utilizing sound methodology. Facilitates the development of quality improvement initiatives. Serves as the clinic’s Risk Manager to assess and identify the potential risks that may tarnish the safety, reputation, and financial sustainability of the organization. Facilitates quality improvement and Risk Management efforts. Serves as the subject matter expert for quality improvement processes and regulations within assigned departments. Directly supervises the Compliance and Quality team. Ensures that these functions and programs meet the organization’s needs and goals. Works with the Human Resources Department related to hiring, training, evaluating, disciplining, and termination of personnel they directly supervise. Oversees the organization’s risk management program, assessing, identifying, and advising leaders to resolve the risks that could impede the reputation, safety, security, or financial success of the organization. Ensures all FTCA requirements are identified and met, including FTCA actions and claims at HHS. Facilitates work of the Patient-Centered Medical Home Team, Risk Management Team, Quality Assurance Utilization Review Committee, and other committees as needed to monitor and track performance measures. Is the HHS lead of the HHS Quality Assurance/Performance Improvement (QAPI) committee. Oversees, and is responsible for submission of UDS (Uniform Data System) and patient satisfaction data collection and reporting. Investigates independently and acts on matters related to compliance, including the flexibility to design and coordinate internal investigations, and any resulting action with all departments, contracted vendors, including Office of Civil Rights, US Department of Health and Human Services, and any other entities HHS is responsible for completing investigations and reviews. Engages in consistent reliability testing, conducting planned and random rounding and mock surveys in all areas of the organization to ensure survey readiness. Organizes, compiles, designs audit tools, performs data analysis, and prepares reports related to clinic objectives and outcomes, establish priorities, and recommend improvement activities as required by grants, contracts, PHI, and/or clinic needs. Performs comprehensive, concurrent, and retrospective reviews in a timely manner, using criteria developed and approved by the medical staff and CCSO. Coordinates the Emergency Preparedness plan with the Peoria City/County Health Department. Reviews policy and procedure related to quality and compliance for the organization and each department, making recommendations for improvement and advising the implementation of essential modifications. Ensures that the healthcare services rendered meet or exceed professionally recognized standards of care. Acts as the Executive Sponsor of the HHS Quality Assurance/Performance Improvement (QAPI) committee. Provides leadership and extends accountability to leaders through the development, implementation, and monitoring of quality improvement and compliance programs, systems, and initiatives. Directs leaders to facilitate performance and process improvements in keeping with patient safety, strategic objectives, and regulatory requirements. Identifies potential quality, compliance, and risk management needs by analyzing data, observing processes, and talking with staff. Fields assigned patient calls related to HIPAA violations, requests for patient information, and patient complaints and concerns. Provides and ensures education and training of new employees, staff, board of directors, on quality improvement activities related to clinic organizational objectives, compliance, and individual job functions, i.e., OSHA, HIPAA, FTCA, PMCH, etc. in consultation with HHS leaders and supervisors. Cultivates and maintains professional relationships with providers, leaders, and other staff to foster opportunities for improvement in quality metrics, enhanced customer service, and to positively impact core measures, i.e., HRSA, HHS, etc. Assists in creating, monitoring, and supervising implementation of the annual Health Care Plan as required by the HRSA (Health Resources and Services Administration) BPHC (Bureau of Primary Health Care) 330 federal grant. Maintains up-to-date understanding of regulatory compliance objectives and communicates these changes to leadership, providers, and others. Maintains professional affiliations, enhances professional development, and serves on any external committee to keep current in the latest health care trends and issues. Serves as the Privacy/HIPAA Compliance Officer for HHS by reviewing all system-related information security plans throughout HHS to ensure alignment between security and privacy practices with the IT department. Maintains and assures confidentiality of patient information in accordance with HHS’s policies. Develops and maintains the monitoring of agreements to ensure all legal and privacy responsibilities are addressed. Attends all staff meetings, department meetings, in-services, seminars, as required. Performs other duties as assigned. Requirements Minimum 5+ years of experience with 3+ in QAC leadership roles. Experience in identifying, developing, and implementing organization-wide compliance initiatives. Experience hosting and supporting regulatory authority inspections. Audit experience required. Ability to proofread and check documents for accuracy daily. Must be able to creatively work with other health care professionals, maintain effective professional relationships from a variety of disciplines. Experience with complex regulatory filing(s) and post-approval regulatory activities. Prior experience working in a startup/clinical stage biotech or pharmaceutical company is a plus. Result-driven with ideas to drive continuous improvement process simplification with breakthrough solutions, including digital. Demonstrated strong cross-functional leadership skills. Well versed with Quality and Compliance management system(s). Quality auditing experience preferred. The ability to creatively solve problems through individual and/or programmatic action. Electronic Medical Records (EMR) experience preferred but not required. Ability to travel to all locations and meetings outside of the service area; flexible hours required.
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Heartland Health Services provides high quality health care services to all. Regular Office Hours: Monday- Friday: 8:00am- 4:30pm. Walk-ins welcome. Health Benefits Start Day 1 of Employment - No Waiting Position Summary The Director of Quality and Compliance (DQCO) provides clinical and administrative services and demonstrates the knowledge and skills necessary to provide quality assurance that is appropriate to the ages of the patients served, in accordance with Heartland Health Services’ (HHS) mission and strategic goals, federal and state laws and regulations, performance and outcome objectives, and accreditation standards. Essential Functions Responsible for providing consultation and education related to clinical quality and patient safety, accreditation, FTCA, PCMH, regulatory and licensing, risk management, and infection prevention and control; contributing to the evaluation, design, and development of evidence-based guidelines, principles, and/or programs related to area of work as well as facilitating implementation efforts to reduce variation in clinical practice and optimize patient outcomes; assisting with the collection, analysis, report development, and presentation of clinical data for a variety of users including for state, federal, and local agencies; monitoring, reporting, and developing mitigation plans for all occurrences which may lead to liability, fraud, etc. for HHS. Listens to, seeks, and addresses performance feedback; proactively provides actionable feedback to leaders verbally and in writing. Adapts to and learns from change, challenges, and feedback; demonstrates flexibility in approaches to work; champions change and helps others adapt to new tasks and processes. Facilitates team collaboration to support the strategic priorities of HHS. Develops and utilizes quality improvement performance metrics to establish improvement success; collaborates with multiple stakeholders, often with competing/conflicting objectives, to ensure development of cohesive and reachable metrics are practical and approved; and facilitates the collection of metric data from workflows and projects by utilizing sound methodology. Facilitates the development of quality improvement initiatives. Serves as the clinic’s Risk Manager to assess and identify the potential risks that may tarnish the safety, reputation, and financial sustainability of the organization. Facilitates quality improvement and Risk Management efforts. Serves as the subject matter expert for quality improvement processes and regulations within assigned departments. Directly supervises the Compliance and Quality team. Ensures that these functions and programs meet the organization’s needs and goals. Works with the Human Resources Department related to hiring, training, evaluating, disciplining, and termination of personnel they directly supervise. Oversees the organization’s risk management program, assessing, identifying, and advising leaders to resolve the risks that could impede the reputation, safety, security, or financial success of the organization. Ensures all FTCA requirements are identified and met, including FTCA actions and claims at HHS. Facilitates work of the Patient-Centered Medical Home Team, Risk Management Team, Quality Assurance Utilization Review Committee, and other committees as needed to monitor and track performance measures. Is the HHS lead of the HHS Quality Assurance/Performance Improvement (QAPI) committee. Oversees, and is responsible for submission of UDS (Uniform Data System) and patient satisfaction data collection and reporting. Investigates independently and acts on matters related to compliance, including the flexibility to design and coordinate internal investigations, and any resulting action with all departments, contracted vendors, including Office of Civil Rights, US Department of Health and Human Services, and any other entities HHS is responsible for completing investigations and reviews. Engages in consistent reliability testing, conducting planned and random rounding and mock surveys in all areas of the organization to ensure survey readiness. Organizes, compiles, designs audit tools, performs data analysis, and prepares reports related to clinic objectives and outcomes, establish priorities, and recommend improvement activities as required by grants, contracts, PHI, and/or clinic needs. Performs comprehensive, concurrent, and retrospective reviews in a timely manner, using criteria developed and approved by the medical staff and CCSO. Coordinates the Emergency Preparedness plan with the Peoria City/County Health Department. Reviews policy and procedure related to quality and compliance for the organization and each department, making recommendations for improvement and advising the implementation of essential modifications. Ensures that the healthcare services rendered meet or exceed professionally recognized standards of care. Acts as the Executive Sponsor of the HHS Quality Assurance/Performance Improvement (QAPI) committee. Provides leadership and extends accountability to leaders through the development, implementation, and monitoring of quality improvement and compliance programs, systems, and initiatives. Directs leaders to facilitate performance and process improvements in keeping with patient safety, strategic objectives, and regulatory requirements. Identifies potential quality, compliance, and risk management needs by analyzing data, observing processes, and talking with staff. Fields assigned patient calls related to HIPAA violations, requests for patient information, and patient complaints and concerns. Provides and ensures education and training of new employees, staff, board of directors, on quality improvement activities related to clinic organizational objectives, compliance, and individual job functions, i.e., OSHA, HIPAA, FTCA, PMCH, etc. in consultation with HHS leaders and supervisors. Cultivates and maintains professional relationships with providers, leaders, and other staff to foster opportunities for improvement in quality metrics, enhanced customer service, and to positively impact core measures, i.e., HRSA, HHS, etc. Assists in creating, monitoring, and supervising implementation of the annual Health Care Plan as required by the HRSA (Health Resources and Services Administration) BPHC (Bureau of Primary Health Care) 330 federal grant. Maintains up-to-date understanding of regulatory compliance objectives and communicates these changes to leadership, providers, and others. Maintains professional affiliations, enhances professional development, and serves on any external committee to keep current in the latest health care trends and issues. Serves as the Privacy/HIPAA Compliance Officer for HHS by reviewing all system-related information security plans throughout HHS to ensure alignment between security and privacy practices with the IT department. Maintains and assures confidentiality of patient information in accordance with HHS’s policies. Develops and maintains the monitoring of agreements to ensure all legal and privacy responsibilities are addressed. Attends all staff meetings, department meetings, in-services, seminars, as required. Performs other duties as assigned. Requirements Minimum 5+ years of experience with 3+ in QAC leadership roles. Experience in identifying, developing, and implementing organization-wide compliance initiatives. Experience hosting and supporting regulatory authority inspections. Audit experience required. Ability to proofread and check documents for accuracy daily. Must be able to creatively work with other health care professionals, maintain effective professional relationships from a variety of disciplines. Experience with complex regulatory filing(s) and post-approval regulatory activities. Prior experience working in a startup/clinical stage biotech or pharmaceutical company is a plus. Result-driven with ideas to drive continuous improvement process simplification with breakthrough solutions, including digital. Demonstrated strong cross-functional leadership skills. Well versed with Quality and Compliance management system(s). Quality auditing experience preferred. The ability to creatively solve problems through individual and/or programmatic action. Electronic Medical Records (EMR) experience preferred but not required. Ability to travel to all locations and meetings outside of the service area; flexible hours required.
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