Director of Quality and Compliance (RN license required)

Alive Hospice, Inc.   Nashville, TN   Full-time     Nursing
Posted on March 25, 2021
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Director of Quality and Compliance (active RN license required)
Location: Nashville, TN 
Status: Full Time, 
Are you a Quality/Regulatory Compliance professional who desires to work in a leadership capacity in which your efforts directly impact clinicians, patients and their loved ones?
If you are eager to use your talents and skill set in a way that truly makes a difference
in the Middle TN healthcare market, we can't wait to talk with you!
The Director of Quality and Compliance provides direction and oversight of performance improvement through data and quality and compliance measurements to provide direction and oversight of the QAPI with leading process improvement efforts to ensure compliance with agency, local, state and national quality initiatives. 
The Director of Quality and Compliance is also responsible Identifying and assessing areas of compliance risk for the organization; communicating the importance of the QAPI program to executive management and the Board of Trustees;  preparing and distributing the written Code of Conduct setting forth the ethical principles and policies, which are the basis of the Compliance Program; developing and implementing education programs addressing compliance and the Code of Conduct; implementing a retaliation-free internal reporting process, including an anonymous telephone reporting system; and collaborating with executive management to effectively incorporate the Compliance Program within system operations and programs and to carry out the responsibilities of the position.
For purposes of clarification, Compliance is defined as all health care regulatory compliance including OIG, CMS, TJC, and HIPAA and other regulations that directly or indirectly impact the operations of Alive Hospice.
  • Quality
    • Collaborate with the VP of Information Technology and Security for optimization of Agency information systems to support and improve processes
    • Facilitation of Root Cause Analysis (RCA), Failure Mode Effects Analysis (FMEA), and Performance Improvement efforts
    • Data gathering to identify opportunities for performance improvement
    • Collaboration with stake holders to ensure reporting needs are identified/met
    • Analytic support for departments across the organization
    • CMS quality reporting
    • Incident reporting and service recoveries
    • Collaborate with Deyta for collection/reporting of family satisfaction surveys
    • Contract management
    • Electronic Medical Record (EMR) enhancement support
    • Collaborate with VP of Information Technology and Security to design and/or refine data tools and systems to streamline agency processes
  • Compliance
    • Monitoring the Compliance Program to help the organization prevent and/or detect violation of law, regulations, policies, or the Code of Conduct.
    • Regularly reviewing the Compliance Program and recommending appropriate revisions and modifications, including advising Executive Management and the Board of Trustees of potential compliance risk areas.
    • Coordinating resources to ensure the ongoing effectiveness of the Compliance Program.
    • Implementing and operating retaliation-free reporting channels, including an anonymous telephone reporting system 
    • Developing education programs for all employees, agents, affiliated providers, or others working with the organization.
    • Ensuring that the internal controls are capable of preventing and detecting significant instances or patterns of illegal, unethical, or improper conduct by employees, agents, affiliated providers, or others working with the organization.
    • Ensuring that the system has effective mechanisms to reasonably determine that persons either promoted to or hired in management and certain other sensitive and/or responsible positions (to be designated) do not have a propensity to violate federal or state laws and regulations or engage in improper or unethical conduct in their designated areas of responsibility.
    • Providing input and/or direction to Human Resources policies and procedures and the performance appraisal and incentive programs to ensure that improper conduct is discouraged and that support of and conformity with the Compliance Program is part of any performance evaluation process for all employees.
    • Coordinating as appropriate with outside legal counsel, conducting or authorizing and overseeing investigations of matters that merit investigation under the Compliance Program.
    • Overseeing follow-up and, as applicable, resolution to investigations and other issues generated by the Compliance Program, including development of corrective action plans, as needed.
    • Presenting reports on the Compliance Program to the Board of Directors.
    • Developing and implementing annual review of updates to Compliance Plan.
    • Reporting on a regular basis to the Board appointed Quality and Compliance Committee on matters involving the Compliance Program. Additionally, the Compliance Officer  is expected to regularly report issues to the VP of Finance and Board of Directors.
    • Working with Executive Management to provide adequate information to employees of to ensure that they have the requisite information and knowledge of regulatory issues and requirements to carry out their responsibilities in a lawful and ethical manner.
    • Ensuring that all contracts contain language which is corporate compliant
    • Representing the board appointed Quality and Compliance Committee, including developing appropriate agendas, reports, and information as directed from time to time by the committee.
    • Oversee, coordinate, and monitor the day-to-day compliance activities of Alive Hospice and the adherence to the Code of Conduct.
    • In consultation with legal counsel, establish a company compliance manual; Maintain and supplement the manual as necessary.
    • Develop and coordinate appropriate compliance training and education programs for all employees.  
    • Ensure and understand the company's commitment to comply with all laws, regulations, company policies, and ethical requirements applicable to the conduct of the business.
    •  Assess the need for additional training and education and develop appropriate compliance programs.
    • Develop, coordinate, and/or oversee internal and external audit procedures 
    • Formalize and monitor a system to enable employees to report any noncompliance without fear of retribution, ensuring that the reporting system is adequately publicized and ensure that allegations of noncompliance are investigated and responded to promptly.
    • In consultation with the Human Resources Department, help ensure that there is a mechanism in place for disciplining instances of noncompliance (including the failure to prevent, detect, or report any noncompliance), appropriate to the nature and extent of the deviation, and ensure consistency in the application of disciplinary action.
    • Work with the Human Resources Department to ensure a work force with high ethical standards, including the establishment of minimum standards for conducting appropriate background and reference checks on potential employees.
    • Continually improve the Code of Conduct program and implement any necessary changes on an ongoing basis to improve the prevention and detection of any noncompliance.
    • In conjunction with the legal counsel, interface and, when appropriate, negotiate with external regulatory agencies.
    • Report to the board appointed Quality and Compliance committee at its regular as otherer wise when necessary, on any significant compliance issues to ensure appropriate discussion of such compliance issues and to ensure that appropriate action is taken.
    • Carry out all duties and responsibilities as assigned by the board appointed Quality and Compliance Committee and/or under the Corporate Integrity Program.
    • Performing other duties as assigned
  • Overall:
    • Work collaboratively as a part of the Leadership team 
    • Ensure compliance with all business regulations for departments for whom direct supervision responsibilities are granted to include but not limited to:
      • Human Resource standards of practice and compliance
      • Health Insurance Portability and Accountability Act for security and privacy of protected health information and other related provisions
      • Compliance with Stark and Anti-Kickback statutes including but not limited to referral relationships
      • CMS and The Joint Commission standards as applicable to departments supervised
      • All other business regulations that govern Alive Hospice practices.
    • Complete annual training in a timely manner
    • Provide input and/or direction to Human Resources policies and procedures 
    • Monitors clinical staff compliance with appropriate orientation, staff development, in service education and other educational plans.
    • Participates in Board and Board committee meetings at the request of the Board and/or the President/CEO.
    • Maintains and develops knowledge of evolving hospice and palliative care philosophy and practices.
    • Recruits, selects, orients, mentors, and disciplines staff based on agency policy, practice guidelines, and staffing.
    • Develops protocols and algorithms for process management in conjunction with other directors as needed.
    • Other duties may also be assigned.
  • Manages\supervises employees involved with quality, compliance, analytics, medical records,
  • Responsible for the overall direction, coordination, and evaluation of these teams.
  • Carries out supervisory responsibilities in accordance with the organization's policies and applicable laws. 
The agency requires this position to complete 18 hours of continuing education per year covering topics that will contribute to improvements in carrying out the above responsibilities. Regulatory agencies may require some disciplines to have additional hours in order to be licensed or certified.
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Bachelor’s degree, Master’s preferred; Active RN License required; CPHQ (Certified Professional in Healthcare Quality) preferred; 3-5 years Clinical Informatics background; demonstrated professional experience working with clinical records, documentation, billing and auditing. 
An active RN License is required for this position. If required to drive to carry out the duties of this position: current driver’s license and automobile insurance as required by Tennessee State Law.