Corporate Compliance & Quality Assurance Director

  • Full-time

Company Description

Community Clinic, Inc. (CCI) is a nonprofit, community-based health care agency serving residents of Montgomery and Prince George's counties who are uninsured or under-insured and others. CCI welcomes adults and children in need of primary health care and WIC nutrition education and food supplement services, provided in 11 accessible locations. CCI is committed to your good health and has been serving the community since 1972. Our expert, dedicated and certified staff are well-trained and friendly. If you are looking for a patient-centered medical home, we can offer you a full array of primary care and WIC services to get well and stay healthy.

Job Description

The Corporate Compliance and Quality Assurance Director (CCQA) is responsible for recommending, implementing and monitoring all performance improvement activities throughout the organization including improvement of clinical and non-clinical processes. As Compliance Officer, he/she is authorized to investigate all instances of suspected illegal or unethical conduct and may, upon obtaining appropriate authorization, and consistent with CCI’s budget constraints, seek the advice of qualified legal counsel.  The CCQA in collaboration with the medical, dental and behavioral health leadership is responsible for ensuring adherence to licensing standards, outcome measures and the provision of high quality services to all services areas within CCI.  The CCQA is assured direct access to CCI’s CEO. The Chief Compliance Officer, reports to the CEO, unless the matter involves CCI’s CEO in which case the CCQA may report independently to the Board of Directors and to qualified legal counsel, in accordance with CCI’s Policy and Procedure.

The CCQA will act as a resource person to collect, respond to, and monitor patient feedback, patient complaints/feedback, incidents, and sentinel events.  The CCQA will collect, analyze, and monitor data regarding process improvement projects, and incidents.  The CCQA is responsible for Joint Commission Survey coordination, including maintaining the process of continuous quality improvement following the survey and maintaining CCI preparedness between surveys. This position reports to the CEO

Corporate Compliance

•    Development, implementation, oversight and evaluation of all aspects of CCI’s Compliance Program;
•    Directs methods to improve efficiency and quality of services to reduce CCI’s vulnerability to fraud and abuse, such as periodic audits, developing effective lines of communication on compliance issues, handling patient feedback and complaints and preparing, maintaining, implementing, and disseminating written practice standards and procedures.
•    Develops, coordinates, and participates in training programs that focus on the Compliance Program and seeks to ensure that all board members, as well as employees, contractors, agents, consultants, volunteers, and others who act on CCI’s behalf are knowledgeable of, and comply with, pertinent Federal and State standards and the requirements of CCI’s Compliance Program.
•    Ensures that the Department of Health and Human Services, Office of Inspector General’s List of Excluded Individuals and Entities, and the General Services Administration’s Excluded Parties List System have been checked with respect to all board members and Staff, as well as all applicants for Board or Staff positions;
•    Responds to all reports or allegations of unethical or improper conduct;
•    Coordinates with the CEO regarding the enforcement of disciplinary action related to compliance, quality assurance or fraud;
•    Reports information on the activities of the Compliance program to the CEO and Board/Compliance/ Committee of the Board.
•    Serves as CCI’s Privacy Officer
•    Other duties as assigned by the CEO, CMO, or COO.

Quality Assurance & Quality Improvement

•    Leads all risk management initiatives at CCI. Develops and promotes a system for incident reporting, review of trends, risk mitigation and training.
•    Implements any Performance Improvement Plans (PIP) in accordance with our mission and strategic goals, federal and state laws and regulations, and Joint Commission accreditation standards.
•    Recommends and implements systems, policies, and procedures for the identification, collection, and analysis of performance measurement data.
•    Analyzes patient survey data to identify opportunities for improvement and presents findings to appropriate department(s). 
•    Oversees the Joint Commission accreditation process, performs Mock Surveys as well as ongoing staff JC preparedness.
•    Oversees and implements the Peer Review process for all CCI Clinical and reports results at department meetings.
•    Provides orientation of newly hired employees to Performance Improvement, Policies and Procedures and Joint Commission.
•    Collects and summarizes performance data, identifies opportunities for improvement, and prepares presentation of findings to bi-monthly PI Committee.
•    Analyzes patient survey data to identify opportunities for improvement, presents findings to appropriate department(s) and assists in developing processes for improvement.
•    Actively participates on, or facilitates, committees such as Performance Improvement, EOC, Infection Control and others.
•    Ensures all performance improvement activities are managed and performed according to regulatory and accreditation standards, corporate policies, and related measures.
•    Demonstrates competency in practice and knowledge of current standards of practice.  Maintains credentials and performs current practice expectations within established guidelines.
•    Develops and maintains favorable internal relationships, partnerships with co-workers, including clinic managers, nursing staff, providers and business office staff.
•    Develops and maintains favorable external relationships with vendors, contractors, and related resources.
•    Ensure all actions, job performance, personal conduct and written and verbal communications represent the organization in a highly professional manner at all times.
•    Uphold and ensure compliance and attention to all corporate policies and procedures as well as the overall mission and values of the organization.

Qualifications

•    Bachelor’s degree in health care management, clinical profession, or related field
•    2 for more years’ experience in health care setting
•    Working knowledge of process improvement methodology
•    Experience in Corporate Compliance and Quality Improvement
•    Demonstrate knowledge and expertise in performance improvement in the health care setting.
•    Demonstrate high degree of knowledge and competency in the medical field and associated charting requirements.
•    Demonstrate a high level of problem solving skill to better serve patients and staff
•    Strong attention to detail and accuracy
•    Excellent verbal and written communication skills
•    Ability to implement, and evaluate operational and administrative processes

Additional Information

All your information will be kept confidential according to EEO guidelines.