Location: Staunton,VA, USA
Title: Regulatory Compliance Coordinator/Assistant QM Manager
State Role Title: 49172
Hiring Range: commensurate based on experience
Pay Band: 5
Agency: Dept Behavioral Health/Develop
Location: Western State Hospital
Agency Website:
Recruitment Type: General Public - G
Job Duties
Western State Hospital is seeking a full time Regulatory Compliance Coordinator/Assistant QM Manager who will serve as assistant QM Manager under the direction of the Hospital Quality Manager; assist in the administrative and management of the Quality Management Program; overseeing hospital compliance with Joint Commission standards for accreditation and the Centers for Medicaid and Medicare Services (CME) Conditions of Participation in addition to other applicable state and federal regulations; overseeing of Utilization Review Coordinator; facilitating/coordinating hospital Performance Improvement efforts, identified pro-risk analysis and root cause analysis as applicable; systematic and objective collaboration with leadership and front-line staff; and coordinating survey or investigating visit follow-ups, including development and monitoring of correction action plans.
The Regulatory Compliance Coordinator/Assistant QM Manager will also ensure that performance planning and evaluation systems are met and evaluations are completed by established deadlines with proper documentation; participate in the development of QM policies and procedures; support facility mission to maximize utilization of resources; set/develop selection criteria for performance improvement projects, explore performance improvement models and tools to gather and assess data; assure on-going awareness of QM priorities by hospital staff, including definitions, tools, and understanding of their roles, etc.; maintain a regulatory dashboard for hospital compliance to reflect status of perpetual readiness plan; and monitor compliance with action planning as required by regulatory or accrediting bodies.
This position is eligible for:
* retirement with cash match
* life insurance
* paid time off
* health, vision, and dental insurance
Minimum Qualifications
* experience with electronic health record and computer skills including Microsoft Office and Excel
* knowledge of state and federal policy, procedures, rules and regulations regarding Quality Management and documentation requirements to ensure compliance and to facilitate proper reimbursement for services
* knowledge of standards of external review and hospital monitoring bodies (The Joint Commission, CMS, etc.)
* ability to analyze and interpret data into meaningful conclusions and recommendations
* ability to communicate effectively with a variety of professional disciplines, both orally and in written form
* ability to work at a high level of productivity; including prioritization of own work with minimal supervision
Additional Considerations
* Bachelor's degree in related field (e.g. social work; health information; mental health) and extensive experience in accreditation in a hospital setting
* certified professional in Healthcare Quality (CPHQ) and/or Lean Six Sigma
* supervisory experience
* bilingual
* veteran
Special Instructions
You will be provided a confirmation of receipt when your application and/or rsum is submitted successfully. Please refer to Your Application in your account to check the status of your application for this position.
The successful applicant must pass a criminal background investigation, drug screening test and employment reference check. The applicant must have the ability to perform at the level of physical demands noted on the Employee Work Profile and the verified ability to perform the essential functions of the position.
Commonwealth's Alternate Hiring Process: In support of the Commonwealth's commitment to inclusion, we are encouraging individuals with disabilities to apply through the Commonwealth Alternative Hiring Process. To be considered for this opportunity, applicants will need to provide their Certificate of Disability (COD) provided by a Vocational Rehabilitation Counselor within the Department for Aging & Rehabilitative Services (DARS), or the Department for the Blind & Vision Impaired (DBVI). Veterans are encouraged to answer Veteran status questions and submit their disability documentation, if applicable, to DARS/DBVI to get their Certificate of Disability. If you need to get a Certificate of Disability, use this link: or call DARS at 800- ###-####, or DBVI at 800-###-####.
DBHDS is a healthcare organization and must comply with the federal CMS Omnibus COVID-19 Health Care staff Vaccination Regulation which requires all employees to be vaccinated or receive an exemption. Upon acceptance of a job offer, new recruits will be asked to disclose their vaccination status (and for those fully vaccinated, proof of vaccination) during the pre-employment process. New staff who are not vaccinated for any reason or choose not to disclose their vaccination status, will need to request a medical or religious accommodation. If you have questions, please contact the Office of Human Resources.
Contact Information
Name: Samantha Leep
Phone: 540-###-####
Email: ...@dbhds.virginia.gov
In support of the Commonwealth's commitment to inclusion, we are encouraging individuals with disabilities to apply through the Commonwealth Alternative Hiring Process. To be considered for this opportunity, applicants will need to provide their AHP Letter (formerly COD) provided by the Department for Aging & Rehabilitative Services (DARS), or the Department for the Blind & Vision Impaired (DBVI). Service-Connected Veterans are encouraged to answer Veteran status questions and submit their disability documentation, if applicable, to DARS/DBVI to get their AHP Letter. Requesting an AHP Letter can be found at AHP Letter or by calling DARS at 800-###-####.
Note: Applicants who received a Certificate of Disability from DARS or DBVI dated between April 1, 2022- February 29, 2024, can still use that COD as applicable documentation for the Alternative Hiring Process.