Director Quality Management/Compliance Officer

75 Vanderbilt Ave, Staten Island, NY 10304, USA

Req #11961

Monday, June 3, 2024

Director of Quality and Compliance (https://cottonwoodcanyonhc.com/director-staff-development/)

The Director of Quality and Compliance strives to ensure that all Agency personnel adhere to regulatory requirements, including but not limited to the Federal Conditions of Participation (COPs), New York State Department of Health Regulations outlined in NYCRR 10 section 763, Medicare and Medicaid billing rules and other governmental oversight and that services provided meet the highest quality standards.

This position also performs a variety of other duties including oversight of patient rights and patient confidentiality and privacy standards; patient satisfaction surveying; infection control and risk management; policy and procedure development and maintenance; compliance with licensing, and health monitoring and mandatory facility education requirements; emergency management; and performance improvement.

Duties and Responsibilities

Development, implementation, and evaluation of the Agencys Quality Assessment Performance Improvement Program (QAPI).

Development, implementation, and evaluation of the Agencys Corporate Compliance Program. Serves as the Agencys Compliance Officer. Ensure effective staff training and monitoring of problem prone areas of compliance.

Development, implementation, and evaluation of the Agencys Emergency Management Program. Ensures effective staff training; ensures drills are performed including completion of after action reports; and ensures completion of the annual Hazard Vulnerability Assessment (HVA).

Development, review and revision of Agency policies and procedures to ensure alignment with regulatory requirements. Maintains the policy and procedure manual. Provides guidance to all staff on Agency policy.

Development, implementation, and evaluation of the Agencys program related to patient privacy and confidentiality to meet all federal Office of Civil Rights Health Insurance Portability Accountability Act (HIPAA) regulations. Serves as the Agencys Privacy Officer.

Participates in all external auditing including but not limited to NYS DOH surveys, and Medicare and Medicaid auditing. Develops and ensures implementation of plans of correction and ensures that responses to all auditing are timely. Maintains records of auditing.

Oversight of complaint resolution. Ensures timely follow-up and documentation. Maintains the Agencys complaint log per DOH requirements.

Oversight of services provided through outside vendors. Reviews all vendor documents to ensure compliance with regulatory requirements prior to contracting. Ensures all contracts meet regulatory requirements and Agency policy.

Monitors Agency quality measures related to OASIS and claims-based outcomes and HHCAHPS. Maintains accounts on iqies and HHCAHPS sites to obtain quality data.

Oversight of Medicare Expedited appeals and conventional Medicare appeals process. Maintains records of all appeals. Serves as the Agencys contact with the Medicare QIO.

Oversight of risk management, including documentation and maintenance of patient and staff incident reporting. Serves as liaison with Agency attorneys related to legal action.

Oversight of patient medical record release to ensure compliance with HIPAA regulations according to minimum necessary rules.

Oversight of quarterly utilization review and other record auditing related to regulatory requirements, performance improvement, plans of correction and other focused reviews.

Development of training programs related to the COPs/DOH regulatory requirements, QAPI, Corporate Compliance, HIPAA, and Emergency Management. Participates in orientation and annual mandatory inservice development and implementation.

Serves as the Agencys coordinator on NYS Health Commerce System. Responds to DOH HERDS reports when required.

Maintains relationship with the Home Care Association of NYS. Keeps abreast of information from NYS DOH, CMS, NGS, OCR, OIG, OMIG and shares information with Agency leadership.

Works with the Agencys VP of Clinical Operations and Staff Development to develop the orientation and educational programs to meet regulatory requirements.

Works with Human Resources to understand regulatory requirements as they pertain to personnel.

Supervises the Quality Management Clinical Analyst and the Quality Management Assistant.

In collaboration with each department, provides the appropriate guidance to ensure adherence to regulatory requirements.

Other job duties as assigned.

Committee Responsibilities:

Quarterly Professional Advisory Committee

Quarterly Corporate Compliance Committee

Annual and ad hoc Emergency Management Team

Job Qualifications Required

New York RN licensure

Minimum two years home care experience in a Certified Home Health Agency

Minimum one year experience with quality management preferred.

Knowledge of applicable federal and state laws and regulations

Ability to write reports, policy, and other correspondence.

Ability to work with and through people to establish goals, objectives, and action plans.

Knowledge of technology to track and streamline data.

Ability to interpret statistical information and to create statistical displays.

Knowledge of change management

Education, Knowledge, Skills and Abilities Preferred

Education leading to RN licensure, preferably BSN.

Master's Degree preferred.

Federal Conditions of Participation for Home Health Care

NYS DOH regulations for Home Care

OASIS

HHCAHPS

Word, Excel, Power Point

Other details

Pay Type Salary

Min Hiring Rate $115,000.00

Max Hiring Rate $140,000.00

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75 Vanderbilt Ave, Staten Island, NY 10304, USA