Quality Assurance Risk Management Specialist

LAC VIEUX DESERT BAND OF LAKE SUPERIOR CHIPPEWA INDIANS

LVDHC HUMAN RESOURCES
P.O. Box 9, N5241 Hwy 45 Watersmeet, MI. 49969

Phone: 906-358-4587 Fax: 906-358-4118

JOB DESCRIPTION

POSITION: Quality Assurance Risk Management Specialist

LOCATION: LVD Health Center, Watersmeet, MI

SUPERVISOR: Director of Facilities & Compliance

EMPLOYMENT: Full Time – Non-Exempt

SALARY/PAY RATE: Based on Experience & Qualifications

UPON HIRE:

• PTO Upon Hire

• Dental

• Vision

• Health Insurance

DESCRIPTION:

The purpose of the Lac Vieux Desert Health Center (LVDHC) Continuous Quality

Improvement and Assurance Program is to have an organized system in place with a

continual goal to strive for excellence. This position develops and maintains an active,

integrated, organized, ongoing, data-driven, and peer -based quality improvement

program that ensures quality care is provided, evaluated, and sustained improvements are

made.

RESPONSIBILITIES:

Quality Assurance/Quality Improvement:

• Assure initiatives align with multiple quality guidelines, such as National Quality

Performance and Results Act (GPRA), Standards of Care, Standards of Practice,

and other evidence-based recommendations

• Leads the Continuous Quality Improvement, Quality Assurance Committee
  

• Responsible for collecting, tracking, and trending data and benchmarking to

records

• Develops and maintains a written quality improvement program with ongoing

concerns

• Ensure quality improvement plans are in line with the organization’s missions and

• Remains current and knowledgeable of all quality mandates from regulatory and

• Compares internal performance measures to external benchmarking and results

• Coordinate with departmental managers in creating meaningful quality assurance

closing plans

• Ensure compliance with federal, state and local healthcare quality and safety

• Ensures data analysis is documented to demonstrate that continuous quality

• Assists directors and departmental leaders in defining performance indicators and

• Facilitate communication and collaboration among departments to promote a

Provider Credentialing:

• Responsible for Provider Initial and re-credentialing by auditing applications for

education, DEA and board certifications

• Compiles and maintains current and accurate data for all providers.
• Responsible for maintaining peer review schedules and compiling necessary

documents to present to the Medical or Dental Director for completion

AAAHC Accreditation:

• Responsible for the coordination of AAAHC accreditation. Coordinates the

participating in on-site surveys, coordinating agendas, and assigning

tasks, tracking activities

• Leads accreditation/regulatory efforts in the planning and development of a

• Provides consultation and acts as a resource to leadership, managers, and staff on

• Provides recommendation for training and development opportunities to support

• Develops and revises policies and procedures to comply with current guidelines

Risk Management:

• Develops, implements and annually reviews the Risk Management Plan

• Manages complaints and grievances in relation to quality assurance
• Manages the process of review and resolution of all incidents and potential or

actual adverse events

• Ensures departmental leadership, maintains and documents full compliance with

safety regulations, management of hazardous materials, and employee health and

infection control programs

• Interprets new, revised, or upcoming regulations and standards and assists in

• Responsible for evaluating patient satisfaction surveys and sharing the

Infection Prevention and Occupational Health:

• Serves as the designated Infection Preventionist (IP) and Occupational Health

• The IP is certified and trained in Infection Prevention Control
• Responsible for policies and procedures within the organization related to

infection control in the Medical and Dental departments and employee health

• The IP provides consultation, education and training to staff and Physicians

• The IP oversees active monitoring and surveillance of Infection Control within

• Ensures proper sterilization techniques and hygiene practices
• The IP immediately implements corrective or preventative measures when

problems are identified

• Manages the LVDHC employee vaccination records and is responsible for pre-

blood exposures and employee illness

• Coordinates preparation of departmental reports, studies, and audits
• Must maintain confidentiality of all patient or client information
• All other duties as assigned

QUALIFICATIONS:

• Licensed or certified health care professional preferred (RN, LPN, CPQH etc.)
• Certification in Infection Prevention or willingness to become certified
• Experience in accreditation or regulatory survey process in a health care setting is

a must

• A minimum of three years’ experience in health information, quality, or risk

• Knowledge of relevant regulatory requirements
• Experience with implementation of corrective action plans

WORK ENVIRONMENT/PHYSICAL DEMANDS

• Fast paced with occasional high pressure or emergent situations

• May wear PPE such as gloves or a mask

• Frequent interaction with a diverse population including team members,

providers, patients, insurance companies and other members of the public

• Frequent sitting, standing, walking, reaching, grasping, carrying, and speaking

• Occasional bending, stooping, lifting less than 20 pounds

• Lifting, carrying, pushing, and pulling up to 50 pounds, with assistance if needed

• Frequent use of computer, keyboard, fax and copy machine, and telephone

This position is considered a sensitive position and is subject to drug and alcohol testing.

All offers of employment are conditional based on the applicant submitting to and

successfully passing a drug and alcohol screen which includes THC and future random

drug testing in accordance with LVDHC’s testing procedure.

Posting Expiration Date: May 5th, 2025

Preference will be given to qualified individuals of American Indian descent.

The above statements are intended to describe the general nature and level of work performed by people assigned to

this classification. They are not intended to be construed, as an exhaustive list of all responsibilities, duties and

skills required of personnel so classified. Management retains the right to add or to change the duties of the

position at any time. Must be able to pass a pre-employment drug screen and applicable background checks related

to the position.

Lac Vieux Desert Health Center Mission Statement: The Lac Vieux Desert Health

Center strives to provide excellence in health care and to inspire a culture of wellness.

Date Approved by the Tribal Council: 5/16/2019 Updated: 4/08/2025

LVD Health Center

Human Resources Department

P.O. Box 9, N5241 US 45

Watersmeet, MI 49969

Email: careers@lvdhealthcenter.com

Website: http://www.lvdhc.org

Phone: 906-358-4587 Ext. 102

Fax: 906-358-4118

SIGNED: _________________________________________ DATE: ___________