What are the responsibilities and job description for the Manager, Education, Compliance and Quality position at MorseLife Health Systems?
SUMMARY
The Education, Compliance, and Quality Manager oversees hospice compliance, ethics, quality measurement, and education initiatives to ensure continuous service improvement. This role identifies compliance risks, communicates them to leadership, and integrates compliance into operations. Additionally, this role oversees privacy policy implementation and staff training in accordance with applicable Federal and state laws.
ESSENTIAL DUTIES AND RESPONSIBILITIES
Leadership:
This position does not have any supervisory responsibilities.
QUALIFICATIONS EDUCATION and/or EXPERIENCE
To perform this job successfully, an individual must be able to perform each primary function satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required.
Ability to work with mathematical concepts and to apply concepts such as fractions, percentages, ratios, and proportions to practical situations.
The Education, Compliance, and Quality Manager oversees hospice compliance, ethics, quality measurement, and education initiatives to ensure continuous service improvement. This role identifies compliance risks, communicates them to leadership, and integrates compliance into operations. Additionally, this role oversees privacy policy implementation and staff training in accordance with applicable Federal and state laws.
ESSENTIAL DUTIES AND RESPONSIBILITIES
Leadership:
- Direct and lead compliance and quality functions.
- Monitor organizational compliance and quality indicators.
- Develop and oversee training and education programs.
- Lead performance improvement initiatives and data reporting.
- Serve as an active member of the Executive Team.
- Develop, update, and monitor compliance policies and the Code of Conduct.
- Serve as the subject matter expert on accreditation and liaise with accrediting bodies.
- Conduct independent audits to ensure compliance.
- Maintain compliance files and databases.
- Oversee HIPAA Privacy policies, staff training, and risk assessments.
- Investigate compliance issues and enforce privacy regulations.
- Report compliance outcomes to leadership and governing bodies.
- Develop and implement the Quality Assessment and Performance Improvement (QAPI) program.
- Track and analyze quality performance, adverse events, and compliance with improvement plans.
- Ensure documentation, patient safety initiatives, and accreditation survey preparedness.
- Oversee Hospice Items Set data submission, Hospice Outcomes Patient Evaluation Assessment compliance and Consumer Assessment of Healthcare Provider Systems reporting.
- Serve as a resource for data analysis and performance improvement projects.
- Maintains awareness of new quality trends, practice tools, and techniques to determine usefulness and applicability to this organization.
- Serves as the resource for leadership on regulatory standards and survey compliance.
- Serves as the lead team member to maintain survey readiness and supports the administrative and clinical team during surveys by assisting with the preparation, implementation, and reevaluation of plans of correction.
- Reports all suspected cases of resident abuse and neglect including sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.
- Develop and manage annual education plans for all staff.
- Oversee Learning Management System (LMS) compliance.
- Ensure training for Hospice Aides, general orientation, and competency assessments.
- Leads the planning, preparation, and presentation of clinical orientation.
- Leads the planning, preparation, and presentation of long-term care educational programs, including both traditional and classroom and computer-based settings.
- Mentor new hires and ensure education aligns with agency quality initiatives.
- Provide continuing education for internal staff and external clients.
This position does not have any supervisory responsibilities.
QUALIFICATIONS EDUCATION and/or EXPERIENCE
To perform this job successfully, an individual must be able to perform each primary function satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required.
- Bachelor’s degree in nursing or related field required.
- Master’s in Healthcare Administration (MHA), Business (MBA), or CPA preferred.
- Professional certification (HCCA) is preferred.
- Proficiency in Word, Excel, and PowerPoint.
- Strong leadership, communication, and problem-solving skills.
- Knowledge of HIPAA and healthcare regulations.
- Ability to analyze data, prioritize tasks, and meet deadlines.
- High integrity, trust, and customer service focus.
- Flexibility, ability to handle stress, and strong interpersonal skills.
Ability to work with mathematical concepts and to apply concepts such as fractions, percentages, ratios, and proportions to practical situations.
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