ORGANIZATION INFORMATION:

POSITION SUMMARY:

The Director of Quality Assurance will lead Equitas Health’s Quality Management program and implementation of the annual Quality Assurance plan.  QA is integrated in all aspects of business and clinical operations across the organization and owned by all providers and employees.  The Director of QA works closely with leaders and staff to build quality assurance into workflows, deploying effective education, training, communications and a regulatory change management process.  This position serves as the organization’s Compliance Officer and is responsible for ensuring the organization is compliant with federal, state and local government regulations.  This includes developing, monitoring and revision of policies and procedures that address risk management, HIPAA compliance, 340B pharmacy and other regulatory requirements.

ESSENTIAL JOB FUNCTIONS:

Essential functions of the job include, but are not limited to local and regional travel, personnel management, leading organizational change, analytical and problem solving to direct process improvement, audit preparation, program compliance, quality outcomes and reporting, strategic planning, maintain staff and patient confidentiality, effectively manage multiple and simultaneous responsibilities, and strong communication and interpersonal skills.

Job Responsibilities:

• Co-Chairs the Quality Assurance Committee for the organization. Ensure the QA Committee provides evidence that the organization has systems in place to meet the Seven Elements of an Effective Compliance Program. Such evidence must contain trending data that is both accurate and can be used in predictive analysis.
• Create an FQHC Compliance Program that meets Section 330 of the Public Health Services Act and the requirements outlined in the Health Center Program Compliance Manual promulgated by HRSA.
• Develop and foster effective collaboration between departments and programs to ensure an integrated approach to quality, safety, and performance improvement. Communicate effectively to facilitate positive working relationships and achieve desired outcomes.
• Use an equity and social justice lens to support more equitable analyses and evaluation and bring greater awareness/understanding of the correlation between health disparities and health outcomes.
• Direct the day-to-day execution of the strategies and tactics necessary to successfully improve the outcomes and results of the organization.
• Manage organizational attestations, trainings, incident reporting, and policies.
• Implement Quality Management and Annual QA Plan(s), and provide Board of Trustee’s an Annual QA Report. Provide Board of Trustees with regular reports on health center and clinical compliance.
• Collaborate with the Chief Medical Officer in improving clinical quality measures across all service lines.  Participate in activities associated with evaluating performance in value based care.
• Create annual audit plan for high risk areas, with particular attention to billing; coding; documentation; HIPAA; investigations; cybersecurity; fraud, waste & abuse; grants management; vendor relations; and revenue protection in general.
• Participate in the development and timely review of organizational policies, procedures, and programs and provide continuing guidance to all employees on quality assurance matters that have implications for all departments.
• Collaborate across departments and update the following Operational Policies & Procedures: Compliance, HIPAA, Safety, 340B, Risk Management, Emergency Preparedness.
• Perform annual HIPAA risk assessments by ensuring the agency is in compliance with the Security Rule’s administrative, physical, and technical requirements.
• Work with Human Resources to create, implement, update, and ensure compliance with the Employee Handbook.
• Ensure systems are in place to meet compliance requirements of all federal, state and local laws, including but not limited to HIPAA, OSHA, 340B, HRSA, HUD, CDC and other regulatory guidelines, and accreditation requirements (CARF, URAC). 
• Establish an open communication environment that encourages all employees to report any suspected illegal conduct or other conduct that violates any policy or procedure, or any applicable law or regulation.
• Appropriately document and investigate incident reports submitted by employees. Provide data to Quality Committee giving them an understanding of the reporting made by staff.
• Ensure department directors review and attest to department-specific policies and procedures.
• Ensure, as appropriate, that the National Practitioner Data Bank, state licensure records, the HHS-OIG’s List of Excluded Individuals/Entities, and the General Services Administration’s (GSA’s) List of Parties Debarred from Federal Programs are regularly checked with respect to applicable employees, medical staff, and contractors.
• Annually review the OIG Office of Civil Rights Work Plan and amend the QA Manual and Audit Schedule as necessary to accommodate federal government’s priorities.
• Collaborate with external auditors whenever necessary.

• Ensure best practices are met in service areas provided by Equitas Health, if possible and practical.
• Maintain departmental regulatory and accreditation compliance by ensuring staff are competent, and take actions to improve. 
• Collaborate with Safety and IT to monitor, implement and revise Equitas Health’s Emergency Preparedness Program.
• Collaborate with patient experience specialist on grievance policies and organizational activities are followed.
• Manage timesheets, performance reviews and other management requirements for Quality Staff; provides ongoing coaching, feedback and support to develop competency and capacity to successfully meet the goals of the department and further the mission of the organization.
• Contribute to a positive work environment by demonstrating unconditional positive regard to patients, clients, employees and stakeholders. Promote and participate in continued learning that supports greater cultural humility and affirming interactions.
• Other duties as assigned.

Knowledge, Skills, Abilities and other Qualifications:

• Requires healthcare compliance certification (CHC) or 7 years of experience in healthcare compliance.
• Experience with operationalizing quality assurance program processes and workflows, doing so in a community health center is preferred.
• Effective interpersonal skills including the ability to develop a rapport with all employees at all levels in order to cultivate an environment conducive to reporting possible legal and policy violations. Ability to competently follow through on investigating such potential violations.
• Strong written and verbal communication skills a must.
• Ability to work independently and efficiently with minimal supervision, including the ability to complete projects in a timely manner in a fast-paced and changing environment with multiple priorities and objectives.
• Must have sensitivity to, interest in and competence in cultural differences, HIV/AIDS, minority health, sexual practices, chemical dependency and a demonstrated competence in working with persons of color, and the LGBTQIA community.  
• Proficiency in all Microsoft Office applications and other computer applications required. 
• Must have reliable transportation and valid Ohio driver’s license.

 Other Information:

Hours are varied including some evenings and weekends.  Background and reference checks will be conducted.  In accordance with Equitas Health’s Drug-Free Workplace Policy, pre-employment drug testing will be administered.  Individuals are not considered applicants until they have been asked to visit for an interview and at that time complete an application for employment.  Completing the application does not guarantee employment.