Quality Compliance Director

Quality Compliance Director | Las Cruces Recovery Center | Las Cruces, New Mexico

About the Job:

PURPOSE STATEMENT:

The Director of Risk Management & Quality Improvement plans, organizes, directs, and controls all aspects of risk management activities to prevent and/or minimize losses associated with identifiable risk and to minimize and prevent claims of general and professional liability against the hospital. Also responsible for conducting and implementing work plans, systems, processes, and policies designed to ensure compliance with all licensures, insurance, accreditation, and certification agencies, federal, and state regulations and laws. Tracks incidents to identify trends and evaluate the effectiveness of corrective measures. Identifies, communicates, and takes action on potential and actual exposures, problem prone and high-risk areas to avoid, minimize, assume, or transfer risk to ensure a safe environment for the protection of clients, employees and visitors to the facility. Directs and monitors the development and implementation of the overall Hospital quality assessment process to ensure safe and excellent client care delivery and to promote high reliability organization.

Roles and Responsibilities:

ESSENTIAL FUNCTIONS:

• Oversees risk management activities to include incident management and reporting, investigation of all serious incidents and potential exposure to liability, processing of insurance claims, communication with attorneys, subpoena management and open litigation functions.
• Oversees incident reporting system to include tracking, investigative follow-up, education, corrective action and maintaining database for reporting and monitoring purposes.
• Leads a team of highly engaged members through hiring, orienting, performance assessment and management, motivating, training, scheduling, and coaching to meet department goals and ensure effective and efficient department operation.
• Facilitates intensive analysis or root cause analysis post sentinel events or ‘near-misses.
• Identifies high risk areas through the performance of proactive evaluation, auditing and monitoring of client encounters, medical record documentation and quality metrics. Collaborates and develops effective working relationships with clinical and medical staff for prevention of clinical risks throughout the facility.
• Investigates and analyzes actual and potential risks in the facility; assess liability and probability of legal action for potential notification.
• Implements risk management program throughout the facility. Develops and implements infrastructures and systems that support client safety.
• Works with internal auditors, security contractors, and other staff to establish an internal control system.
• Maintains database of full disclosure activities and provide oversight for review programs and provides technical support as needed.
• Conducts review for facility wide problems and trends.
• Investigates, plans, implements and assesses corrective action.
• Integrates the findings of all risk management activities, as appropriate, with the clinical services program where there are opportunities to improve the quality of client care.
• Accurately performs chart audits and closed chart reviews related to complaints, grievances, allegations or incidents, as applicable.
• Monitors and directs the day-to-day operations of quality management and compliance process within the organization to establish and maintain a culture of compliance and safety.
• Continually assesses the hospital survey readiness. Functions as survey coordinator during any regulatory survey. In consultation with key managers, prepares responses to survey and addresses recommendations and areas needing improvement.
• Coordinates regulatory activities including licensure and accreditation (OHFLAC, BHHF, CMS, Joint Commission, Office of Civil Rights, etc.). Serves as liaison to the regulatory agencies related to activities within the organization.
• Sets expectations, develops plans, and manages processes to measure, assess and improve the quality of clinical programs and/or regulatory/accreditation compliance by measurable results.
• Develops, reviews, and updates internal clinical procedures, related outcomes measurement, client satisfaction, clinical/financial scorecards to ensure ongoing compliance with federal, state, and other third-party regulatory requirements.
• Responds to alleged violations of rules, regulations, and policies, by evaluating and recommending investigations as appropriate. Coordinates resolution of ethics reports with appropriate staff/department.
• Maintains proficiency in regulatory planning strategy and the submission of regulatory plans. Develops corrective action plans for the resolution of problematic issues or to address areas of compliance vulnerability.
• Collects and provides data for compliance requests, dashboards, and scorecards. Prepares and submits accurate and comprehensive reports as required both internally and externally.
• Oversees the coordination of internal and external governmental compliance/privacy investigations or reimbursement reviews at the facility to ensure investigations/reviews are conducted appropriately and that responses to external entities are consistent with facility standards and expectations.
• Provides research, analysis, and consultation on regulatory requirements. Maintains current and updated facility accreditation and regulatory standards manuals.
• Ensures proper facility reporting of incidents and adverse clinical outcomes to duly authorized enforcement agencies or regulatory agencies as appropriate and/or required

EDUCATION/EXPERIENCE/SKILL REQUIREMENTS:

• Bachelor’s degree in healthcare, risk management, human services or Nursing required. Master’s Degree in same field preferred.
• Five or more years’ experience in risk management, quality / performance Improvement / compliance, hospital credentialing / licensure / survey process required. Behavioral health setting preferred.
• Knowledge and understanding of applicable TJC ‘Risk’ standards and regulatory compliance and state / local regulations from applicable licensing agencies.
• Experience with TJC accreditation and regulatory audits preferred.

LICENSES/DESIGNATIONS/CERTIFICATIONS:

• Professional clinical license issued by the appropriate licensing body as required by the state.
• CPR and de-escalation and restraint certification required (training available upon hire and offered by facility).
• First aid may be required based on state or facility.

SUPERVISORY REQUIREMENTS:

Two or more years’ health care supervisory/management experience required, preferably in behavioral health.

Why Las Cruces Recovery Center?Las Cruces Recovery Center offers a comprehensive benefit plan and a competitive salary commensurate with experience and qualifications. Qualified candidates should apply by submitting a resume. Las Cruces Recovery Center is an EOE.

Veterans and military spouses are highly encouraged to apply. Summit BHC is dedicated to serving Veterans with specialized programming at our treatment centers across the country. We recognize and value the unique strengths of the military community in supporting our mission to serve those who have served.