Job Detail: Director, Quality Improvement/Corporate Compliance
Officer Only registered candidates can reply to Jobs.
Report to: President/Chief Executive Officer for Compliance
Program and Chief Medical Officer (CMO) for Quality Improvement
ADA: Full time position. Ability to sit and perform computer
entry work for duration of work day. Must be able to drive to all
OSHA: Must adhere to universal precautions, to include blood
borne pathogen protection, at all times.
This is a highly responsible position that is directly under the
supervision of the Chief Executive Officer and Chief Medical
Officer for its two components. The person holding this position is
expected to provide leadership, technical expertise and management
of the Corporation's Quality Improvement and Compliance Program.
The person holding this position works in collaboration with the
Senior leadership team, the Clinical Support Services Coordinator
and leadership at the Center level.
In conjunction with the Quality Improvement Coordinators,
performs data retrieval for performance improvement activities as
indicated. This includes but is not limited to: Chart audits,
management reports, and incident reports.
Prepares, or has prepared, all information for Corporate QI
meeting; i.e. minutes, hand-outs, performance improvement plans
Coordinates and establishes timetables for QI/QA departmental
procedure manual updates. With the assistance of the QI staff and
leadership teams, determines Quality Improvement/ Quality Assurance
objectives and activities for the upcoming year.
Keeps CMO informed regarding the organization's QI/QA
performance status and issues at all times.
Stay current with regulations, laws, PI methodology and QI/QA
associated measurement tools through continuing education (NACHC,
FACHC, AHIMA, meetings, trainings, and other program related
agencies and activities).
Develop and provide training (directly or via designees)
regarding the QI/QA plan, process and activities for all
Provide leadership, supervision and training for members of the
QUALITY AND COMPLIANCE:
Responsible for the development and implementation of the
Quality Improvement/Quality Assurance Plan and the Corporate
Responsible for the annual review and update of the
organization's Quality Improvement/Quality Assurance Plan and
Compliance Plan and providing leadership for the company wide
Performance Improvement processes.
Chairs Board and Corporate Quality Improvement/Safety Committees
to be held every month.
Monitors laboratories, in conjunction with the Laboratory
Coordinator, for compliance with CLIA regulations. Keeps the
Florida State and CLIA licenses current and up to date. Notifies
appropriate agencies as changes are made.
Responsible for incident reporting (receiving incident reports
and reviewing them with the appropriate Senior leadership). This
also includes providing direction of completing root-cause analysis
(RCA) and recommending performance improvement plans in response to
Submits monthly QI/RISK management reports to the Board of
Directors (BOD). This includes information regarding FCHC Quality
Measure performance and associated QI/QA activities. Regularly
provides updates regarding TJC and PCMH status to the BOD. Leads
the monthly BOD QI Committee. Assures the BOD reviews and approves
the Corporate QI/QA plan no less than annually.
Works with Senior and Center Management to assist and ensure
compliance with the QI Plan and Corporate Compliance Plan with
internal (policy/procedure) and external (contract/program)
Participate with regional networks, if applicable.
Facilitates, with the assistance of Senior Management, the
development tools, guides, brochures, surveys, etc., necessary for
the corporate compliance and QI/QA programs of FCHC.
Performs other duties relating to Quality Improvement and
Corporate Compliance as may be directed by the Chief Medical
Officer and Chief Executive Officer, respectively.
Maintains employee hotline and monitors for complaints and
potential fraud/abuse reports.
Responsible for investigating all reports of potentially
improper/illegal activities and reporting results to CEO and Board
Responsible for handling and responding to medical malpractice
claims or allegations (compiling medical records, completing
documentation responses for Administrative Tort Claims and
informational requests, and disseminating litigation hold
Responsible for overseeing status updates to medical malpractice
claims or allegations (updating files with received notices and
maintaining records for FTCA application updates). This also
includes providing the Board of Directors a status report at
Keeps CEO informed regarding Compliance status and issues of the
Corporation at all times.
Develop training for all employees in corporate compliance
In coordination with the CEO, keeps current with relevant OIG,
CMS, Federal, State and local regulations and laws, fraud alerts,
and other regulatory agency rules and regulations.
Must possess a minimum of a MD/DO, RN or appropriate Masters
Must have at least five (5) years experience in quality
improvement related activities and management experience. Knowledge
of statistics, data collection, and survey design helpful.
SKILLS AND ABILITIES:
Must be able and willing to travel within six (6) county service
area and outside the area to occasional workshop and/or
Must be computer literate.
Must demonstrate leadership ability
Knowledge of management techniques and procedures necessary for
problem solving, conflict resolution, and program development.
Knowledge of health care delivery systems, inclusive of medical
Knowledge of CLIA 88 regulations.
Knowledge of quality improvement standards as they relate to
Knowledge of current Federal, State and local laws and
Ability to collect and analyze quality improvement data in a
Ability to implement quality improvement policy accurately and
Ability to work cooperatively with all department supervisors to
develop QI activity schedule.
Ability to keep all data collected in a neat, organized
Ability to communicate clearly in written and interpersonal
**This job description is not intended to be all-inclusive, and
employee will also perform other reasonable related business duties
as assigned by supervisor.
This organization reserves the right to revise or change job
duties and responsibilities as the need arises. This job
description does not constitute a written or implied contract of
Status Director of Compliance and Quality Improvement Only
registered candidates can reply to Jobs.
Florida Community Health Centers, Inc. is a FTCA deemed
facility. This health center is a Health Center Program grantee
under 42 U.S.C. 254b, and a deemed Public Health Service employee
under 42 U.S.C. 233(g)-(n).