Quality and Compliance Manager

Full-Time Position:

• Exempt Salaried Monday through Friday hours 8 am - 5 pm
• Salary commensurate with experience

The full-time Quality and Compliance Manager position is a fully benefited position, which includes:

• Medical, dental, and vision insurance
• Life and disability insurance
• 401(k) plan with employer match
• Paid time off
• Paid holidays
• Continuing education assistance

Summary:

Responsible for helping to ensure Hospice of Holland meets the regulatory requirements set in the Medicare Conditions of Participation, operates within the HIPAA confidentiality rule and remains complaint with local, state and federal laws and accreditation. Responsible for assisting the Senior Director of Operations with management of all quality improvement systems, procedures and processes for the organization at large.

Responsibilities of the Quality and Compliance Manager include but are not limited to:

• Maintains current knowledge related to Medicare Conditions of Participation, QAPI standards, the HIPAA Privacy Rule, and state, federal, and accreditation guidelines to ensure the agency is compliant in all areas.
• Provides direction for all quality improvement activities utilizing continuous improvement principles and methodologies.
• Facilitates the compilation, trending and reporting of quality data in the areas of patient care, safety, risk management, infection control, outcomes and customer satisfaction. Assists with identifying areas for improvement.
• Functions as the Security Compliance Officer. Assists with medical records requests.
• Reviews all incident reports for completeness, risk, standard of care determination and appropriate follow up.
• Assists with the compilation, trending and reporting of quality data in the areas of patient care, safety, risk management, infection control, outcomes and customer satisfaction. Assists with identifying areas for improvement.
• Acts as a resource to the Senior Director of Operations regarding nursing compliance, nursing regulations, safety and risk management, leadership team members, clinical supervisors, and staff at large.
• Assists in the design, development and review of all HOH clinical policy and procedures related to quality assurance and compliance.
• Facilitates and performs regular on-going chart review of all HOH patients to ensure corporate standards for documentation are met and reports findings to appropriate clinical leadership for follow-up as needed.
• Assists with gathering information and review of chart contents for purposes of root cause analysis, corrective action, and other reporting needs.
• Acts as a super-user for the electronic medical record for use in accessing data for reporting functions and remains available for staff assistance when/as needed.
• Participates in Medicare state and federal surveys as needed. Helps to facilitate survey preparation with all staff who will be involved in the survey process.
• Helps ensure every person under HOH care receives the best care possible.

Position Qualifications:

• Minimum of a Bachelor’s degree in a related field.
• Minimum of 5 years of prior experience in a related field.
• Prior managerial and/or supervisory experience.
• Excellent interpersonal and communication skills.
• Proven ability to handle sensitive situations and maintain confidentiality.
• Proficiency utilizing technology including Microsoft Office Suite products.

Hospice of Holland is a financially strong non-profit organization deeply committed to providing the best care for hospice patients and their families. The Quality and Compliance Manager plays a critical role in that mission.