Compliance Officer

• Position Description:

The Compliance Officer helps to ensure Regulatory Compliance, Risk Management, Patient Satisfaction and Quality Improvement programs of the Cataract & Laser Center (CLC). The Director of Compliance plays a key role in quality improvement, infection control and risk management. He or she analyzes and evaluates services to improve the quality of care given and maintains policies that adhere to federal and state regulations for Ambulatory Surgery Centers. All Cataract and Laser Center staff are to maintain a positive and professional attitude and collaborate as a team with both colleagues and management to uphold a supportive and respectful atmosphere for both patients and staff. Conduct internal audits to assess compliance with regulations and internal policies.

Duties:

• Provide ongoing program evaluation of CLC and patient care activities as well as maintain continuous compliance and reporting with government regulatory agencies and accrediting bodies including Medicare, AAAHC, Massachusetts Department of Public Health, Board of Registration in Medicine: Patient Safety Division and others as needed.
• Establish, maintain, analyze, and evaluate standards of care for compliance with professional standards and recommended any changes along with the Director of Compliance and the Director of Nursing.
• Monitor, adhere to and keep up to date the shared Inspection Preparedness and Scheduled Facility Events calendar in conjunction with Director of Nursing and Administrative Director.
• Maintains infection control, environmental safety, and quality assurance practices.
• Completes audits, conducts appropriate research, and reports back to the Director of Compliance and management on the audits.
• QA reports

Responsibilities:

• Schedules fire drills with electric company and fire department and participates in disaster drills.
• Quality improvement and reporting and documentation.
• Ensures accurate specimen log and middle room documentation is completed.
• Maintain log and follow through with sharps injuries.
• Resolve patient grievances and complaints in a timely manner.
• Prepare and participate in all licensure processes for the center.
• Stay up to date on Quality and Risk Management regulations (Federal/State/CMS/AAAHC/DPH/CDC/AORN/OSHA/DOH) and educate and train all employees.
• Prepare and perform initial orientation for new staff.
• Maintain monthly infection control log i.e. sharps safety, hand hygiene, infection control as provided by other departments such as nursing.
• Serve as Infection Control Site Resource along with the DOC and DON.
• Maintain a clean and safe environment.
• Ensures all facility equipment is in proper working order and maintain logs and maintenance records.
• Develop study plans based on trends and improvement needs.
• Research, record data, analyze, record corrective actions and remeasurements following AAAHC recommended guidelines.
• Report required information from QAs and patient satisfaction scores to pharmacy consultant.
• Assists in other areas as needed.
• Oversee peer review reports are completed by the appropriate staff.
• Oversee satisfaction surveys and report.
• Oversee quality improvement and reporting.
• Oversee specimen log.
• Oversee CME/ENV inspections and reports.
• Prepare physicians infections/complications monthly report.
• Oversee all facility equipment is in proper working order and maintain logs and maintenance records.

Job Types: Full-time, Part-time

Pay: From $62,400.00 per year

Expected hours: 40 per week

Benefits:

• 401(k)
• Dental insurance
• Health insurance

Ability to Relocate:

• Gardner, MA 01440: Relocate before starting work (Required)

Work Location: In person

Salary : $62,400