Position Summary:
The Director of Quality and Compliance provides leadership and expertise to ensure the delivery of safe, high quality patient care services for the health care organizations of the Eastern Shoshone Tribe including a medical clinic, long term care skilled nursing facility, dialysis center, outpatient behavioral health program, and community health programs. This position will have administrative oversight from the CEO at Warm Valley Health Care, but will report to the Eastern Shoshone Tribal Board.
DUTIES AND RESPONSIBILITIES
- Oversees a quality improvement program inclusive of all Tribal health organizations, develops and maintains a written quality improvement plan and annual evaluation of the plan's effectiveness.
- Develops and maintains a performance measurement work plan and reporting calendar to ensure timely data collection, aggregation, analysis, and reporting of established performance measures related to key operational and clinical processes and outcomes.
- Leads improvement teams and reports on outcomes.
- Manages electronic storage of quality improvement reports to promote ongoing access for key stakeholders.
- Oversees a compliance program inclusive of all Tribal health organizations, develops and maintains a written compliance plan and annual evaluation of the plan's effectiveness; ensures that all required elements of a compliance program are addressed.
- Develops and maintains policies and procedures related to the compliance program.
- Develops and maintains the written Code of Conduct and ensures staff and Eastern Shoshone Tribal Health Board members receive the appropriate training/education.
- Serves as a resource for the key leadership of all Tribal health organizations for all external and internal compliance audits; ensures that corrective action plans are documented in a timely manner and effectively implemented.
- Oversees investigations relating to reports of known or suspected violations of the compliance program or Code of Conduct.
- In consultation with the key leadership and the Eastern Shoshone Tribal Health Board, submits mandatory notifications of known or suspected corporate compliance violations to the appropriate regulatory agencies.
- Develops and maintains up-to-date knowledge of compliance requirements and related laws and regulations as mandated or recommended by OIG, CMS, and other agencies; attends outside compliance training as directed by the Eastern Shoshone Tribal Health Board.
- Oversees a risk management program inclusive of all Tribal health organizations, develops and maintains a written risk management plan and annual evaluation of plans' effectiveness.
- Develops and maintains policies and procedures related to the risk management program.
- Develops and oversees processes for internal incident reporting.
- Reviews incident reports and conducts follow up investigations as warranted.
- Oversees a patient safety program inclusive to all Tribal health organizations, develops and maintains a written patient safety plan and annual evaluation of plan effectiveness and develops and maintains policies and procedures related to the patient safety program.
- Collaborates with the Chief Medical Officer (CMO) of Warm Valley Health Care and/or Medical/Clinic Directors of the health care organizations in the investigation of clinical events including sentinel events near misses, and significant adverse events; leads and/or participates in the development of root cause analyses as directed by the Governing Body.
- Other duties as assigned.
QUALIFICATIONS:
- Master's degree in Public Health, Healthcare Administration or Bachelor's degree and 2-3 years of experience working in the healthcare field.
- Demonstrated leadership skills including excellent oral and written communication skills.
- Strong knowledge of healthcare clinical fundamentals, patient safety standards, and performance improvement standards.
- Strong knowledge of CQI tools and techniques, ability to perform data analytics, and lead performance improvement teams.
- Computer skills and knowledge of applicable software programs.
- Ability to work with diverse population.
- Flexible schedule.
SALARY AND BENEFITS:
Salary commensurate with experience. Benefits for full-time include: Medical/Dental/Vision/Life, Paid Time Off, Extended Sick Leave and 401k.
- Must pass pre-employment drug screening.
- Successfully pass the employment background check.