Apply on Employer Site

Ohio Valley Surgical Hospital · 1 month ago

Quality Director and Compliance Officer (FT)

Springfield, OH

Full-time

Onsite

Director/Executive

Ohio Valley Surgical Hospital is dedicated to providing excellent care for patients and elevating the standard of health care in the community. The Quality Director and Compliance Officer is responsible for ensuring compliance with regulatory requirements and overseeing quality improvement initiatives within the hospital.

Health CareHospitalMedical

Responsibilities

Under the direction of the Quality Medical Director and Chief Nursing Officer, the Quality Director develops and implements a quality and performance improvement (PI) plan and processes

Coordinates quality improvement activities and data collection according to the PI plan

Gathers data, evaluates data, creates reports, promotes action plans, reevaluates processes as needed, reports, and provides a monthly summary/dashboard

Oversee Quality Improvement, Compliance/Ethics, Infection Control, Risk Management, Education, Employee Health, and Hospital Service Line leaders

Assists with the review, development, and implementation of policies, procedures, and plans to proactively manage risk including HIPAA, foster a culture of safety, and prevent illegal, unethical, or improper conduct

Ensures reportable events are reported to regulatory agencies as directed

Collects, investigates, and evaluates risk/compliance related data/concerns and reports to appropriate leadership and/or regulatory agency

Oversee the Compliance hotline and ensure follow-up with appropriate leaders or regulatory agencies on any reported HIPAA or other compliance concern

Completes the compliance plan/dashboard and maintains the core elements (including written policies and procedures, training and education, compliance committee, hotline, internal monitoring and auditing, enforcing standards, response and corrective action and consistent enforcement and disciplinary guidelines) required for an effective corporate compliance program

Review compliance issues, trends, or concerns and act as an independent review and evaluation body to ensure that compliance Issues/concerns within the organization are being appropriately evaluated, investigated, and resolved

Provides guidance for the Board and executive management team on matters relating to compliance

Participates in the investigation and analysis of root causes, patterns or trends that could result in compensatory or sentinel events

Assists to identify and implement corrective action based upon trends, evidenced based practice, and/or root cause analysis where appropriate

Actively participates in facility committees related to infection control, risk management, service lines, emergency management, pharmacy and therapeutics, and safety

Oversee the compliance/ethics and performance improvement committees

Oversee hospital ongoing readiness for regulatory compliance

Monitors, follows-ups, tracks, and reports patient grievances

Oversees service line accreditation programs for continued compliance

Assists leaders with consults to legal counsel as needed to resolve difficult compliance issues, and actual or potential hospital professional liability (e.g. medical malpractice, litigation matters, professional liability, general liability, workers’ compensation, motor – vehicle liability, property, directors/officers, fiduciary liability, ERISA, OSHA, HIPAA, TJC, Medicare and Medicaid regulations, health-care regulations, state reporting requirements, patient safety, and patient consent forms

Develop education about potential risks, liabilities, compliance, and the Code of Conduct

Collaborates with other departments (e.g., Finance, Revenue Cycle, Human Resources, ancillary/nursing departments, etc.) to direct compliance issues to appropriate existing channels for investigation and resolution

Oversee legal claims processing by reporting, investigating, and providing information to legal counsel

Performs other duties as assigned or required

Qualification

Registered Nurse LicenseHealthcare Compliance CertificationMaster's in Nursing (MSN)Legal Compliance ExperienceMicrosoft Office ProficiencyCommunication Skills