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Quality and Compliance Manager

2 months ago

Corvallis, Oregon, United States Lumina Hospice and Palliative Care Full time
Job Summary

Lumina Hospice and Palliative Care is seeking a part-time Quality and Compliance Manager to join our team. This is an in-person/onsite position.

Key Responsibilities
  • Compliance Oversight: Ensure agency compliance with federal and state regulations, including risk assessments and reporting to the Board of Directors.
  • Quality Program Development: Develop, update, refine, and oversee the implementation of the compliance program and day-to-day compliance activities.
  • Quality Assessment and Performance Improvement (QAPI): Develop, update, refine, and oversee the implementation and monitoring of the organization's QAPI Program, ensuring it meets state and federal requirements and enables the organization to achieve its strategic goals and mission.
  • Compliance Program Management: Manage the organization's compliance program, including risk assessments, and report to the Board of Directors on compliance matters.
  • Privacy Officer: Fulfill the role of Privacy Officer as required by federal regulations.
  • Administrative Support: Provide administrative support for staff working evenings, weekends, and holidays under the Administrator on Call (AOC) guidelines.
  • Quality and Compliance Expertise: Maintain current knowledge with the CMS Hospice Quality Reporting Program (HQRP) and be the expert resource for staff on quality, compliance, safety, and HIPAA privacy.
  • Collaboration and Communication: Work collaboratively with clinical managers to ensure documentation is complete and consistent with care and reflects regulatory and legal requirements.
  • Incident Reporting and Review: Review all incident reports for completeness, risk, standard of care determination, and appropriate follow-up, maintaining records for trending and making recommendations related to trends identified.
  • Compliance Education and Training: Develop and coordinate the compliance education and training program, ensuring all relevant employees and management are knowledgeable of and comply with pertinent federal and state standards and regulations.
  • Reporting Mechanism: 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.
  • Regulatory and Accreditation Standards: Monitor organization compliance with regulatory and accreditation standards, conducting mock surveys as requested by the Executive Director.
  • Policies and Procedures: Monitor clinical and administrative policies and procedures to ensure they are complete, current, and in compliance with regulatory, licensing, certification, and accreditation standards, overseeing the development, review, and revisions of all agency policies and procedures.
  • Surveyor Arrangements: Oversee all arrangements with surveyors, both federal and state.
  • Reporting and Data Analysis: Generate reports and extrapolate appropriate, current, and applicable statistical data for Lumina Hospice & Palliative Care's QAPI program, the NHPCO National Data Set, CAHPS, HIS, HQRP, chart review, and other mandated or assigned reporting as needed.
  • Compliance and Quality Data: Display, trend, and report compliance and quality data, including but not limited to clinical, safety, risk management, infection control, and patient/family satisfaction.
  • Employee Orientation and Competency: 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.
  • Safety Programs: Oversee the implementation and monitoring of the organization's safety programs and chair the Safety Committee.
  • Professional Development: Promote self-growth and collegial relationships with others in the hospice and palliative care industry, maintaining professional and technical knowledge by attending educational workshops, reviewing professional publications, establishing personal and professional networks, and participating in professional organizations or societies.
  • Policy Adherence: Understand and adhere to Lumina Hospice & Palliative Care's Privacy Policy, Abuse of Vulnerable Persons policy, and all policies and procedures contained in the Lumina Hospice & Palliative Care Employee Handbook.
Requirements
  • Education: Bachelor's degree required, master's degree in a related field preferred.
  • Experience: Minimum of two (2) years of previous experience working in a healthcare environment, with quality improvement and compliance experience strongly preferred.
  • Skills: 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 ability to design and implement effective staff education and training programs.
  • Commitment: Commitment to serving the needs of the terminally ill.
  • Technical Skills: Intermediate skills in statistics, email, word processing, internet, keyboarding, and ability to use medical software.
Benefits

Lumina Hospice & Palliative Care 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.