This position is responsible for managing and continually improving METRO’s quality and risk management, and compliance program, monitoring compliance/risk activity and investigating allegations of compliance and/or policy infraction. This position reports to the Senior Director of HC Services and collaborates closely with the Medical Director and senior leadership.
- Maintains current knowledge of Federal, State and Accrediting regulations and standards pertaining to ongoing compliance and policy.
- Leads actions to maintain COA Accreditation, HRSA-FQHC Compliance, DCF Licensing and other applicable state and federal licensing and compliance related entities.
- Maintains records and manages all METRO’s contracts for compliance.
- Manages response for subpoenas and oversees Medical Records.
- Manages METRO’s Medical Records department and monitor Medical Record activities for areas of non-compliance
- Maintains and monitors the compliance and records for CLIA Waived testing permissions required by the State, local laws and regulations.
- Implement the onboarding and annual compliance program for staff.
- Interact with and report to senior management on the status of the compliance activities highlighting any areas of potential risk to the agency.
- Works closely with team to identify risk prone program and service activities, including but not limited to, patient confidentiality, health record security, health systems security and privacy.
- Manages Performance & Quality Improvement and Risk Management programs.
- Leads the PQI team and develops quality improvement reports for PQI committee, staff and Board of Directors.
- Researches and recommends strategies and best practices and oversees the implementation of programs to increase client/patient quality, operations and customer service.
- Aggregates annual data and conducts an overall evaluation of the PQI program for efficiency and effectiveness of performance throughout the year.
- Sets the annual PQI work plan and manages frequency of reporting.
- Manages data collection and reporting of HRSA Uniform Data System (UDS) required measures.
- Receives and investigates complaints, near misses, and incidents to resolution.
- Oversees ongoing competency with METRO’s Emergency Preparedness Plan and schedules regular desktop drills to assess current competence among staff.
- Plan communication and training programs to help employees understand their roles in risk management.
- Support Medical Director and Behavioral Health Department in oversight of the peer review process.
- Manages credentialing and privileging files for LIPs and non-LIPs in compliance with FQHC standards and METRO policies, including required competencies and training.
- Manage document management software housing METRO’s policies and procedures, credentialing and privileging items, all staff trainings and contracts, to include staff individual accounts and assignments.
- Minimum Bachelor’s degree in related area.
- At least 3 years of experience in the areas of quality management, risk management, accreditation, and compliance.
- Experience working in an FQHC setting preferred.
Knowledge, Skills and Competencies Required:
- Exceptional planning, communication and organizational skills
- Must be able to take initiative and coordinate projects with high level of independence
- Stellar understanding of compliance, risk and quality management concepts and practices.
- Strong analytical skills and complex problem solving capabilities
- Ability to work effectively independently and motivate others in team oriented projects
- Ability to present complex information in simple concise terms
- Exceptionally detail oriented and strong computer skills required
- Must possess and maintain valid Florida driver’s license and proof of insurance
- Must have reliable and accessible auto vehicle.
- Must pass necessary fingerprinting, Level II background checks and employment eligibility verification through the U. S. Department of Homeland Security’s E-Verify system, https://e-verify.uscis.gov/emp.
To apply for this job email your details to firstname.lastname@example.org