What are the responsibilities and job description for the Director of Quality & Compliance position at LISH?
About Long Island Select Healthcare, Inc.
Long Island Select Healthcare Inc. (LISH) is a comprehensive network of community health centers. We are a Federally Qualified Health Center (FQHC) that provides Article 16 and 28 clinic services at 8 locations across Suffolk County, New York. We are a multi-specialty healthcare provider caring for our community through Primary and Specialty Medical Care, Dental, Behavioral Health, Audiology, Physical Therapy, Occupational Therapy and Speech Language Pathology. We currently provide care to over 7,000 patients and have an annual operating revenue of $22m.
LISH is a Forward-Thinking, Community-Oriented Organization!
NYS Patient-Centered Medical Home
Chronic Care Management Program
Telemedicine & Virtual Care Services Program
Integrated Primary & Behavioral Healthcare
I. General Purpose of the Job
The Director of Quality position is responsible for overall quality improvement activities in addition to Corporate Compliance. The position is also responsible for ensuring that high quality services are provided through a collaborative approach with all staff.
II. Essential Duties & Responsibilities
1. Responsible for planning, implementing and evaluating all aspects of LISH’s Quality Improvement Program.
2. QI activities are part of the daily responsibilities of this position
3. Acts as the Lead for LISH’s NYS-PCMH Program.
4. Serves as the HIPAA Privacy & Security Officer.
5. Provides reports and strategic plans for all Quality programs of LISH.
6. Risk Management activities are a daily responsibility for this position. Responsible for the receipt and review of all medical malpractice claims.
7. Responsible for organizations response, per agency policy, to complaints and claims of medical malpractice
8. Ensures quality programs meet the criteria established by regulatory agencies.
9. Organizes, leads, and oversees Quality Committee meetings.
10. Assists the Leadership Team with development and implementation of quality improvement activities.
11. Ensures proper reporting requirements are met.
12. Works in conjunction with the Nurse Manager to ensure nursing and ancillary nursing staff in their individual functions provide quality patient care.
13. Ensures that Corporate Compliance structures, policies, and procedures are in place and functioning as required.
14. Maintains compliance training records in conjunction with the Human Resources Department.
15. Assures that the 340B Program is operationally sound and works in conjunction with the Nurse Manager to ensure all requirements are met for audits/compliance with HRSA regulations.
16. Oversees the Risk Management program in conjunction with the leadership team.
17. Supports the Quality Review of the CCM program in conjunction with the Nurse Manager.
18. Leads the CQI process to ensure staff compliance with all policies and procedures.
19. Assists in the training and education of all staff with regards to Risk Management, HIPAA, Corporate Compliance, and Quality Assurance.
20. Assists and participates in on and off-site program planning.
21. Participates in Lean and other activities necessary to implement a multi-disciplinary patient-centered medical home approach.
22. Coordinates and facilitates patient flow processes.
23. Other duties as assigned.
III. Supervisory Responsibilities
This position does not have any staff reporting to them.
IV. Qualifications
Experience working with medical teams in NYS-PCMH is required for this position. Bilingual in English and Spanish preferred. A Certification as a Professional in Health Care Quality (CPHCQ) is preferred. PCMH- Certified Content Expert (PCMH-CCE) preferred.
V. Education and/or Experience
Bachelor’s degree in Healthcare Administration or related required. Master’s degree in related discipline preferred. Minimum of 3 years working in a healthcare quality role required. Minimum of 5 years of relevant experience in healthcare preferably in progressive supervisory roles. Strong communication skills and experience working with an EMR (ECW a plus). Experience with Quality Metrics in an Ambulatory Care Setting preferred.
VI. Necessary Skills & Abilities
Language Skills
Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals. Ability to write routine reports and correspondence. Ability to speak effectively before groups of customers or employees of organization.
Mathematical Skills
Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent and to draw and interpret bar graphs.
Reasoning Ability
Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. Ability to deal with problems involving several concrete variables in standardized situations.
Computer Skills
To perform this job successfully, an individual should have basic to intermediate knowledge of Microsoft Office software (Outlook, Excel, Word), as well as Practice Management and Electronic Medical Record software – eClinicalWorks a plus).
VII. Physical Demands
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this Job, the employee is regularly required to use hands to finger, handle, or feel and talk or hear. The employee is frequently required to stand; walk and sit. The employee is occasionally required to reach with hands and arms; climb or balance; stoop, kneel, crouch or crawl, and taste or smell. The employee must occasionally lift and/or move up to 25 pounds.
VIII. Travel
Means and Ability to travel between sites required.
IX. Work Environment
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
The noise level in the work environment is usually moderate.
Tasks do not normally involve exposure to blood, body fluids or tissue; however, work may require the unplanned performance of such tasks, which may expose employee to Bloodborne Pathogens (Category II).
