Quality Director

Description

POSITION SUMMARY:
The Quality Director manages and directs the organization toward its primary compliance, quality and risk management objectives. The Quality Director acts as lead developer and provides direct oversight in the following areas: Quality Assurance and Improvement, Risk Management, Compliance and Pharmacy. The Director is responsible for process initiatives and system improvement for projects such as UDS and Patient Centered Medical Home (PCMH), Risk Management, HIPAA, Emergency Preparedness, Pharmacy & 340B Program, including contract and consultant oversight. The Director works in concert with the KCHC leadership team to achieve the goals set forth in the KCHC Compliance Plan, Risk Management Plan and Quality Improvement Program Plan, maintains PCMH recognition, comprehensively assess and manage risk and patient safety, manage the KCHC HIPAA program, ensure patient satisfaction, and confirm all KCHC personnel are adequately trained and compliant with KCHC protocols and practices. The Director is responsible for managing registration and involvement in the 340B Program for KCHC and certifying that all use of 340B throughout the organization is fully compliant. Responsible for achieving maximum utilization of 340B pricing through full 340B Program participation in all areas of qualified use to include the entity-owned Pharmacy. The Director is also responsible for overseeing the Quality Department’s collections, process, and performance of statistical analyses of data for the overarching purpose of quality improvement and reporting requirements. The Director is a key member of the Administrative leadership team.

ESSENTIAL JOB FUNCTIONS:
Acts as a member of the KCHC healthcare team in the provision of health services to individuals, families, and/or their communities. Works collaboratively with patients and their caregivers – to the extent preferred by each patient – as well as with other members of the KCHC healthcare team to accomplish shared goals within and across settings to achieve coordinated, high-quality care. Provides ongoing guidance, support, and education to other members of the KCHC healthcare team as it pertains to ensuring effective, quality primary care for KCHC patients and their families.
1. Supervise the Quality Department including Pharmacy, Risk and Quality.
2. Oversee the management of the KCHC clinic wide Corporate Compliance Plan, QI Plan and RM Plan, including Board of Directors approval every three years.
3. Assist staff in identifying high-risk areas through risk assessments, incident reports, and other means, and then help develop plans to mediate the risks.
4. Identify methods to reduce KCHC’s vulnerability to fraud and abuse, such as conducting periodic audits, developing effective lines of communication on compliance issues and drafting policies and procedures.
5. Maintains knowledge and expertise on Quality Department related rulings and interpretations, including new and proposed regulations, current trends, and issues.

6. Assesses potential organizational impact of Quality Department changes, (i.e. PDSAs) and ensures Quality Department is continuously compliant internally and with federal regulations.
7. Develops, suggests, and/or updates Quality Department policies and procedures whenever there is a clarification to interpretation, or change in the rules, regulations, guidelines or requirements. Reviews Quality Department policies and procedures annually and ensures all KCHC policies are reviewed then either renewed, revised or revoked, annually by the Executive Director and Board of Directors (BOD), as needed.
8. Oversee periodic review of government and other funding requirements to ensure all changes are incorporated into appropriate policies, procedures and/or plans.
9. Supervise audits and analyzes reports to adhere to the Quality Department policies, ensuring compliance within the clinic on administered drug purchases, billing, third-party entity communication, auditing and other necessary requirements.
10. Ensure orientation of new providers and provide staff training in compliance topics. Collaborate with Human Resources/Administrative Director to ensure the consistent and fair application of disciplinary action, when applicable.
11. Review the processing of all incident and employee injury reports, including tracking responses and outcomes.
12. Supervise HIPAA compliance, in coordination with the Quality Department, Operations Director and KCHC’s IT Department or contracted IT company.
13. Assist Executive Director with organizational or operational reviews, strategic planning and grant compliance.
14. Act as lead in Quality Department reporting and audits.
15. Oversee the Patient Satisfaction Survey program including developing surveys, data tracking and reporting.
16. Leads, assists other directors, and participates in various committees/meetings (i.e., Care Team, 340B Oversight Committee, etc.) to present the program plan overview monthly and/or quarterly.
17. Ensure staff support to Board QI Committee and that the BOD has Quality Department overview updates quarterly.
18. Monitor the established clinical quality measures (CQMs), quality, and productivity reports.
19. Responsible for the high-level overview for accuracy and potential improvement initiatives within the supporting programs that focus on improved outcomes of patient care, patient safety, healthcare delivery systems, EHR, patient billing, quality improvement, patient population, compliance, and grant reporting.
20. Represent KCHC and its services to the community, statewide and nationally as appropriate.
21. Assist as needed in absence of key staff members or in case of a personnel vacancy.
22. Oversee Provider Peer Review processes including chart selection and data tracking.
23. Oversee accuracy and consistency of website information.
24. Work closely with KCHC leadership team to assist in any special projects under their purview.
25. Performs other related duties, as assigned, that support the overall mission and vision of Kodiak Community Health Center.

Qualifications

ESSENTIAL JOB QUALIFICATIONS:
1. Education: Associates, Bachelor’s or Master’s degree preferred. Must be knowledgeable in project management and business operations.
2. Experience: Minimum 3 years’ experience in compliance, business operations, business management, project management, and/or analysis is required. Experience in a healthcare setting using an EHR and medical billing system is highly desired.
3. Licensure/Certification: None
4. Other Qualifications:
a. Communication:
• Ability to effectively communicate, verbally and in writing, with all levels of staff personnel.
• Strong analytical skills with the ability to collect, organize, analyze, and disseminate significant amounts of information with attention to detail and accuracy.
b. Collaboration:
• Team-oriented and able to work collaboratively with staff.
• Strong problem-solving and time-management skills.
• Ability to work independently in a fast-paced, medical office environment with frequent interruptions, public contact, and occasional crisis situations.
• Ability to maintain strict confidentiality with sensitive medical information and foster an ethical work environment.
• Ability and willingness to carry out responsibilities in accordance with the organization's policies and applicable laws.
c. Cultural Competence:
• Demonstrates complete understanding and responds effectively with sensitivity to special populations served by KCHC. Special populations include, but are not limited to, those defined by race, ethnicity, language, age, sex, sexual orientation, economic standing, disability status, migrant, homelessness, seasonal workers, and the uninsured.

5. Attendance: Regular attendance and punctuality is expected and required.
6. English Language: Must be able to read, speak and write English.