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Director of Quality and Risk Management and Compliance Officer
Location:
Montrose, CO
Description:
Position Overview: The Compliance Officer establishes and implements an effective compliance program to prevent illegal, unethical, or improper conduct. The Compliance Officer acts as staff to the CEO and Governing Board by monitoring and reporting results of the compliance and ethics efforts of the company and in providing guidance for the Board and senior management team on matters relating to reporting and compliance. The Corporate Compliance Officer, together with the Corporate Compliance Committee, is authorized to implement all necessary actions to ensure achievement of the objectives of an effective compliance program. Functions as the HIPAA Privacy Officer for the organization. Position Overview: The Director of Quality and Risk Management is responsible for all aspects of the Quality Management Department including the coordination of the efforts of the medical staff and hospital's department managers in the performance and reporting of quality management activities. Essential Functions : Development and maintenance of systems for support of medical staff quality assurance activities including peer review. Data collection and display for identified key result measures. Responsible for ensuring overall organizational TJC or other similar accrediting body requirements as well as Federal and Colorado State Health Department regulations Serves as Risk Manager and is the liaison between the hospital and its liability insurance carrier. Maintains internal incident reporting system as well as reporting mechanisms for incident reporting to the state health department, TJC, and federal agencies. Oversees the Infection Control Practitioner who maintains infection control surveillance and reporting activities as well as providing hospital wide infection control education for staff. Development and maintenance of the Personal Health Program including the Exposure Control and Tuberculosis Control Plans Responsible for oversight of TJC Accreditation. Oversees patient satisfaction. Ensures surveys are conducted through third party vendor and appropriate action is taken as a result of survey data. Physical Demands and Working Conditions: While performing the duties of this job, the employee is regularly required to see, talk and hear. The employee frequently is required to sit and use hands along with fingers, to handle or feel. The employee is required to stand, walk, reach with hands and arms, climb or balance, and stoop, kneel, crouch or crawl. High stress department and requires excellent stress management techniques. Qualifications & Skills: Education: Bachelors degree required. Nursing degree and license preferred. Required Skills: Excellent interpersonal and communication skills needed in interacting with members of the medical staff, peers, patients, public, and outside review and regulatory agencies Minimum Work Experience: Three to five years clinical experience required. Experience in Quality Management required. Essential Functions : • Develops, initiates, maintains, and revises policies and procedures for the general operation of the compliance program and its related activities to prevent illegal, unethical, or improper conduct. • Develops and periodically reviews and updates, in conjunction with the Human Resources Director, Code of Conduct to ensure continuing currency and relevance in providing guidance to management and employees. • Collaborate with other departments to direct compliance issues to appropriate existing channels for investigation and resolution. • Consults with General Counsel as needed to resolve difficult legal compliance issues. • Responds to alleged violations of rules, regulations, policies, procedures, and Code of Conduct. • Acts as an independent review and evaluation body to ensure that compliance issues and concerns within the organization are being appropriately evaluated, investigated, and resolved. • Identifies potential areas of compliance vulnerability and risk. • Monitors the performance of the Compliance Program and relates activities on a continuing basis. • Ensures proper reporting of violations or potential violations, in conjunction with legal counsel, to duly authorized enforcement agencies as appropriate or required. • Provides direction and management of the compliance hotline. • Institutes and maintains an effective compliance communication program for the organization. • Oversees organizations HIPAA Privacy program, including development of policies and procedures, training, investigation of all privacy complaints, and follow-up of all requests from patients who wish to exercise their rights according to the Privacy Rule. • Responsible for MMH service and physician agreements filing and processing to include inputting into MediRegs, maintaining a list of current agreements with termination and renewal reports generated as appropriate and other functions related to the service and physician agreements process as determined by CEO. Physical Demands and Working Conditions: While performing the duties of this job, the employee is regularly required to see, talk and hear. The employee frequently is required to sit and use hands along with fingers, to handle or feel. The employee is occasionally required to stand, walk, reach with hands and arms, climb or balance, and stoop, kneel, crouch or crawl. Qualifications & Skills: a) Education: Bachelors degree required; masters desired. b) Training & Experience: A minimum of 10 years experience in a healthcare organization, to include demonstrated leadership. Familiarity with operational, financial, quality assurance, and human resource procedures and regulations a must. Previous experience as HIPAA Privacy Officer desired. c) Job Knowledge: Corporate compliance and government regulations related to compliance, HIPAA Privacy, Tumor Registry requirements. CHA data requirements. MediRegs and Meditech software. Job Posted by ApplicantPro
Company:
Montrose Memorial Hospital
Posted:
December 26 2023 on ApplicantPro
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More About this Listing: Director of Quality and Risk Management and Compliance Officer
Director of Quality and Risk Management and Compliance Officer is a Executive Compliance Officer Job at Montrose Memorial Hospital located in Montrose CO. Find other listings like Director of Quality and Risk Management and Compliance Officer by searching Oodle for Executive Compliance Officer Jobs.
Director of Quality and Risk Management and Compliance Officer is a Executive Compliance Officer Job at Montrose Memorial Hospital located in Montrose CO. Find other listings like Director of Quality and Risk Management and Compliance Officer by searching Oodle for Executive Compliance Officer Jobs.