Quality & Compliance Manager

Quality & Compliance Manager-Part-time

Lumina Hospice and Palliative Care founded as Benton Hospice Service in 1980, is a community-grown nonprofit, that provides compassionate care and support for individuals, families and caregivers facing serious illness or end of life.

Lumina Hospice & Palliative Care is seeking a part-time (20 hrs. per week/.50FTE) Quality & Compliance Manager to join our team. This is an in-person/onsite position. The Quality and Compliance Manager is responsible for planning, designing, implementing, monitoring, and maintaining a comprehensive hospice quality program and compliance program. The Quality and Compliance Manager is responsible for maintaining knowledge of relevant accrediting/regulatory agencies and standards and is the expert resource and arbitrator when regulatory issues arise.

Your responsibilities will be to:

• Oversee and ensure agency compliance with federal and state regulations.
• Develop, update, refine and oversee the implementation of the compliance program and day-to-day compliance activities.
• Develop, update, refine and oversee the implementation and monitoring of the organization’s Quality Assessment and Performance Improvement (QAPI) Program. Ensure that the quality plan meets state and federal requirements and enables the organization to achieve its strategic goals and mission. Provide routine updates to the Executive Director and Board of Directors on the implementation of the quality management plan. Participate as a member of QAPI Board committee and chair the QAPI staff committee.
• Manage organizations compliance program including risk assessments. Reports to the Board of Directors on compliance matters.
• Maintain current knowledge with the CMS Hospice Quality Reporting Program (HQRP).
• Fulfil the role of Privacy Officer as required by federal regulations.
• Provide administrative support for staff that work evenings, weekends, and holidays under the Administrator on Call (AOC) guidelines.
• Maintain current knowledge related to hospice quality standards. Be the expert resource for staff on quality, compliance, safety and HIPAA privacy.
• Work collaboratively with clinical managers to ensure documentation is complete and consistent with care and reflects regulatory and legal requirements.
• Collaborate with clinical managers in follow-up of concerns expressed by patients, families, and physicians.
• Review all incident reports for completeness, risk, standard of care determination and appropriate follow-up. Maintains records for trending and make recommendations related to trends identified.
• Revise the compliance program in light of any changes in Lumina’s needs and in the law; regulations and policies of federal; state, and private-payer health plans.
• Develop, and coordinate the compliance education and training program. Ensure that all relevant employees and management are knowledgeable of and comply with pertinent federal and state standards and regulations.
• Create and monitor a reporting mechanism that enables employees and contractors to report any non-compliance without fear of retaliation and ensure the reporting mechanism is adequately publicized.
• Monitor organization compliance with regulatory and accreditation standards. Conduct mock surveys as requested by the Executive Director.
• Monitor clinical and administrative policies and procedures to ensure they are complete, current and in compliance with regulatory; licensing; certification, and accreditation standards. Oversee the development, review and revisions of all agency policies and procedures.
• Oversee all arrangements with surveyors, both federal and state.
• Generate reports and extrapolate appropriate, current and applicable statistical data for Lumina Hospice & Palliative Care QAPI program; the NHPCO National Data Set; CAHPS; HIS; HQRP; chart review and other mandated or assigned reporting as needed.
• Responsible to display, trend and report compliance and quality data including but not limited to clinical, safety, risk management, infection control, and patient/family satisfaction.
• Collaborate with clinical managers to provide a process to promote and ensure employee orientation, competency and in-service education programs regarding compliance, quality, safety, and infection control.
• Oversee the implementation and monitoring of the organization’s safety programs and chair the Safety Committee.
• Promote self-growth and collegial relationships with others in the hospice and palliative care industry.
• Maintains professional and technical knowledge by attending educational workshops; reviewing professional publications; establishing personal and professional networks and participating in professional organizations or societies.
• Understand and adhere to Lumina Hospice & Palliative Care Privacy Policy; Lumina Hospice & Palliative Care Abuse of Vulnerable Persons policy; and all policies and procedures contained in the Lumina Hospice & Palliative Care Employee Handbook.
• Other duties as assigned.

Qualifications:

• Bachelor's degree is required and a master's degree in a related field is preferred. Oregon nursing license preferred; BSN / MSN and/or CHPN strongly preferred. LCSW applicants welcome to apply.
• Must have a required minimum of at least two (2) years of previous experience working in a health care environment.
• Quality Improvement and compliance experience strongly preferred.
• Substantial experience in hospice operations with understanding and appreciation of the role of hospice in health care system; clinical experience in a medical setting preferred.
• Demonstrates understanding of federal and state laws and regulations pertaining to Hospice programs.
• Self-directed and able to work with minimal supervision.
• Excellent communication and collaboration skills. Ability to communicate with all levels of staff, including the Board of Directors.
• Strong planning and problem-solving skills and the ability to design and implement effective staff education and training programs.
• Commitment to serving the needs of the terminally ill.
• Intermediate skills in statistics, email, word processing, internet, keyboarding, and ability to use medical software.

Schedule: Part -time, 20 hours/week. Usual hours fall within the 8-5, Monday through Friday workweek although occasional other hours will be required.

*Preferred applicant will be asked to pass a background check and drug screen following a job offer.

**New employees are required to complete tuberculosis screening and provide proof of hepatitis B vaccination or signed declination.

***Must be able to show proof of COVID-19 vaccination.

Lumina Hospice & Palliative Care has the reputation and community trust that comes from a local history of providing outstanding end-of-life care and education and bereavement services to thousands of family’s year over year. We recognize the unique and emotional needs of each patient and family member. Our caring service delivery as a non-profit provider is a reputation we plan to keep.

Lumina offers competitive compensation and a comprehensive benefits package to benefit eligible employees who have regularly scheduled hours of 20-40 each week. Our benefits include premium choices for medical, dental, vision, LTD (Long Term Disability), AD&D (Accidental Death & Dismemberment) and life insurance, along with access to a Flexible Spending Account or a Health Savings Account. Our employees also receive mileage reimbursement, 403 B retirement plan, vacation and sick time accrual, two personal days and 9 paid holidays.

Working for Lumina Hospice & Palliative Care, a community-based nonprofit organization, may make you eligible for the Public Service Loan Forgiveness Program.

Lumina Hospice & Palliative Care is an equal opportunity employer and does not discriminate on the basis of race, religion, color, sex, age, national origin, disability, sexual orientation, veteran status, or any other classification protected by law.