Job Posting for Director of Quality Assurance, Clinical Compliance, and Risk Management at sjfmc
Job Description:
Southern Jersey Family Medical Centers, Inc. is seeking a Director of
Quality Assurance, Clinical Compliance, and Risk Management for a very
successful and very busy Federally Qualified Health Center in Southern
New Jersey.
Summary: The Director of Performance Improvement and Clinical
Compliance "DPICC" ensures compliance with the applicable
regulations and requirements of local health departments, the New
Jersey Department of Health, the Federal Office of Inspector General
(OIG), and Health Resource and Service Administration (HRSA). The
Director ensures that SJFMC adheres to: all regulations and standards
regarding Quality Assurance, HIPAA, organizational policies and
procedures, Infection Control, Risk Management, and Employee and
Patient Safety.
Position Responsibilities/Duties:
Ensures that center locations and clinical programs comply with
all applicable local, state and federal regulations.
In conjunction with the Chief Medical Officer and other members
of the senior management team, develops, updates and implements
the following programs and policies: Quality Assurance, HIPAA ,
Infection Control, Clinical Protocols, & Center’s Policies and Procedures
Reviews, investigates, completes and corresponds to external
clinical audits and information requests, including but not limit
to HEDIS reports and other MCO findings.
Oversees and coordinates the Risk Management Program which
includes reviewing, tracking and trending adverse
incidents/events, HIPAA violation complaints, patient and employee
safety, patient complaints, patient satisfaction surveys, and
providing quarterly reports to senior management and the Board of Trustees
Reviews monthly compliance self-audit checklists for pertinent
NJ regulations governing SJFMC programs for all locations and
conducts unannounced site visits quarterly.
Responsible for daily continuous oversight of the Quality
Improvement/Quality Assurance program, including ensuring the
implementation of QI/QA operating procedures and completion of
QI/QA assessments, monitoring QI/QA outcomes, updating QI/QA
operating procedures, and providing QA Reports at the QA and
Provider Meetings
Responsible for coordinating and appropriately implementing
modifications to heath center policies and procedures to comply
with regulatory changes or to improve quality of care, patient and
employee safety, and for developing and implementation of a plan
for the mitigation of risk factors as they are identified.
Develops, reviews and revises, as appropriate, Policies and
Procedures, to meet compliance with Standards for Licensure of
Ambulatory Care Facilities NJDHS, OIG and HRSA. Evaluates ongoing
compliance with Policies and Procedures.
Ensures compliance with NJDHSS disease and mandatory local,
state and federal reporting requirements
Develops and implement staff education programs consistent
with state, federal and local regulations, including HIPAA,
Information Security, NJ Ambulatory Care regulations, Risk
Management and Infection Control
Ensure that audits are conducted in accordance with an
approved schedule according to the centers’ Quality Assurance
and Health Care plans
Manages identified safety issues including patient
notifications, both written and verbal, of unacceptable behaviors
resulting in warning and/or discharge from the practice.
Must be a superuser for the EMR system and work closely with the
data analysts to produce accurate quality reports.
Reviews after-hours calls to ensure appropriate chart
documentation and conducts follow-up with providers and the CMO as indicated.
Attends Board Meetings as directed by the CEO
Assists CMO with the PEER Review Program
Represents the organization and participate in external meetings
as required.
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