Oversees, coordinates and manages all aspects of the development, implementation and maintenance of SCAHC’s quality improvement and compliance programs; performs quality measurement and performance activities as well as ensuring that SCAHC is compliant with all regulatory requirements.
Essential Functions:
- Plans, designs, integrates, implements, modifies, manages and evaluates the performance improvement program, to measure and improve the quality of patient care and the appropriateness, effectiveness, and timeliness of services provided.
- Analyzes health care data obtained from a variety of sources including but not limited to analyzing data and producing performance improvement reports for analysis and decision-making purposes.
- Provides leadership in improving patient care, maintaining standards of care, and developing and facilitating programs which impact patient care.
- Coordinates performance improvement and compliance activities for external and accreditation reviews; ensures compliance with standards of outside agencies and regulatory authorities.
- Analyzes information using qualitative and/or quantitative analytical methods in order to identify issues and problems requiring additional research and study and takes appropriate action to ensure sound study results.
- Develops, designs and implements clinical quality improvement performance dashboards for SCAHC clinics to improve patient care while focusing on clinical outcomes.
- Assists with the investigation of any possible adverse events.
- Participates in the planning, coordination and presentation of training and educational programs.
- Develops policies and procedures to support the quality improvement programs.
- Develops, implements and oversees satisfaction surveys, quality improvement plans and goal and quality improvement projects.
- Conducts an annual evaluation of the quality improvement program, and provides results and recommendations to the Executive Leadership Team.
- Develops and implements a comprehensive compliance program and organization-wide annual work plan.
- Conducts audits and operational assessments to identify areas of risk and compliance with internal and external policies, procedures, regulations and programs.
- Ensures all accreditation processes are monitored, evaluated and implemented as required.
- Works collaboratively with functional area managers, quality team and executives to develop area-specific compliance plans and monitoring metrics, procedures and dashboards.
- Develops and maintains a comprehensive compliance program and develops annual work plan and submits to the Board for approval.
- Prepares quarterly reports which summarize newly identified risks, status of the annual work plan completion and recommendations for modifications to the previously approved annual work plan.
- Evaluates plans, policies and procedures to identify gaps as they relate to current or emerging regulations or evolving organization needs.
- Performs other duties as assigned.
Minimum Requirements:
- Five years of quality management and/or compliance coordination in a healthcare or hospital setting.
- Two years of experience with healthcare regulatory compliance or internal audit and/or legal background.
- Bachelor’s Degree in Nursing, Master’s degree preferred.
- Certified Professional in Healthcare Quality (CPHQ).
Indian Preference and Equal Employment Opportunity:
SCAHC gives preference in hiring to San Carlos Apache Tribal members and other Native Americans in accordance with the San Carlos Apache Tribe’s Tribal Preference Policy, as set forth in Section 402 of the Tribe’s Human Resources Department Policies and Procedures Manual. Otherwise, SCAHC does not discriminate in any way to deprive any person of employment opportunities or otherwise adversely affect him/her because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, citizenship, veteran status, military or uniformed services, in accordance with all applicable governmental laws and regulations. In addition, SCAHC complies with all applicable federal and Tribal laws governing nondiscrimination in employment.
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