QUALITY ASSURANCE–RISK MANAGEMENT/COMPLIANCE ASSISTANT

Will report directly to the Chief Compliance officer, and report indirectly, and work very closely with the Senior Risk Management/Compliance position. Will be responsible, among other things, for partnering with management and the Chief Compliance Officer to provide continual risk assessment and in the development of comprehensive policies and procedures, compliance training, protocols, internal investigations. Will also perform data collection, data analysis and monitoring of Occurrence Reports (incidents) for the hospital and all satellite locations. Will also be responsible for the analysis and summarization of data from the patient satisfaction surveys (HCAHPS), and will prepare and distribute reports/charts, and ideas on how to improve to the Quality Assurance Committee. Will be responsible for helping to meet all federal and state requirements as it pertains to patient complaints. Will also assist in performing and maintaining HIPAA audits.

Risk Management

Provides strategic oversight for patient safety and clinical risk management programs, including training, data collection, and data analysis and monitoring of all Occurrence Reports.

Reports and summarizes all General and Medication Occurrences reports to the Chief Compliance Officer in a timely manner.

Participates collaboratively in staff meetings, committees, projects and teams to resolve conflicts and meet institutional goals.

Effectively report, investigate, and analyze occurrence reports, especially those pertaining to patient safety, medical errors, or other potential risks in the facility

HCAHPS Coordinator

Review, analyze and trend submissions. Determine approximate scores, and report to Chief Compliance Officer and other management.

Determine areas of improvement and propose new ideas on how to increase scores. Follow-up and trend to determine if scores have improved

Reviews and contributes to the attainment of departmental and hospital goals annually pertaining to HCAHPS scores.

Provide all patient data to third party vendor, in a timely manner as set forth by CMS requirements, ensuring patient data is accurate

Work closely with third party vendor to ensure hospital is meeting all CMS requirements

Compliance

Participates in policy, procedure, and process review, correction, and development

Perform internal compliance investigations and audits throughout the Hospital, including compiling detailed reports with recommendations to the Compliance Officer and management.

Other duties as assigned by the Chief Audit and Compliance Officer from time to time.

Will serve as the Patient Complaints Coordinator, which includes keeping a detailed log of complaints, manager follow up for chart review, contacting the patient, and issuing a recommendations & findings report to the Chief Compliance Officer

Other Duties:
Recalls

Log all recalls that are sent to the hospital

Make sure the recall gets to the appropriate personnel in a timely manner.

Follow-up and make sure the issue has been dealt with and is resolved & log the resolution.

Physician Orders

Responsible for updating, maintaining, and distributing all physician order sets

Qualifications

Education/Certification: High school diploma required, with college degree preferred. Medical background required.

Language/Communication: Must communicate in a timely manner, clearly and effectively, both verbally and in writing.

Mathematical Skills: Competent background in mathematics and statistics is required to perform analyses and compile reports on certain job functions

Mental Capabilities: Work well under pressure. Demonstrates ability to understand and evaluate regulations and guidelines and apply them to the setting of MVH in a manner that will cause the least amount of stress and confusion to the professional staff and patients. Can evaluate suggestions and criticisms objectively and wherever necessary undertakes to change behavior or seek further guidance.

Interpersonal: Demonstrates skills in interpersonal relationships with patients and their families, co-workers, supervisors and management. The ability to influence change without direct authority, and negotiation skills.

Performance: Demonstrates a clear understanding of the highly confidential nature of all facility and patient information and maintains confidentiality of patient information. Demonstrates personal integrity in holding this information in the strictest confidence. Exhibits an attitude, which promotes harmony and goodwill among patients, caregivers, and co-workers. Is self-motivated. Keyboard, word processing and spread sheet computer skills.

PHYSICAL DEMANDS: Intermittent periods of sitting, standing, walking, reaching, and twisting. Occasional need for squatting, bending, and kneeling. Occasionally required to lift and carry up to 10 pounds with some lifting of up to 25 pounds. Requires full range of body motion, manual and finger dexterity and eye-hand coordination there are occasional tasks requiring pulling and pushing of objects up to 25 pounds

Description

Will report directly to the Chief Compliance officer, and report indirectly, and work very closely with the Senior Risk Management/Compliance position. Will be responsible, among other things, for partnering with management and the Chief Compliance Officer to provide continual risk assessment and in the development of comprehensive policies and procedures, compliance training, protocols, internal investigations. Will also perform data collection, data analysis and monitoring of Occurrence Reports (incidents) for the hospital and all satellite locations. Will also be responsible for the analysis and summarization of data from the patient satisfaction surveys (HCAHPS), and will prepare and distribute reports/charts, and ideas on how to improve to the Quality Assurance Committee. Will be responsible for helping to meet all federal and state requirements as it pertains to patient complaints. Will also assist in performing and maintaining HIPAA audits.

Risk Management

Provides strategic oversight for patient safety and clinical risk management programs, including training, data collection, and data analysis and monitoring of all Occurrence Reports.

Reports and summarizes all General and Medication Occurrences reports to the Chief Compliance Officer in a timely manner.

Participates collaboratively in staff meetings, committees, projects and teams to resolve conflicts and meet institutional goals.

Effectively report, investigate, and analyze occurrence reports, especially those pertaining to patient safety, medical errors, or other potential risks in the facility

HCAHPS Coordinator

Review, analyze and trend submissions. Determine approximate scores, and report to Chief Compliance Officer and other management.

Determine areas of improvement and propose new ideas on how to increase scores. Follow-up and trend to determine if scores have improved

Reviews and contributes to the attainment of departmental and hospital goals annually pertaining to HCAHPS scores.

Provide all patient data to third party vendor, in a timely manner as set forth by CMS requirements, ensuring patient data is accurate

Work closely with third party vendor to ensure hospital is meeting all CMS requirements

Compliance

Participates in policy, procedure, and process review, correction, and development

Perform internal compliance investigations and audits throughout the Hospital, including compiling detailed reports with recommendations to the Compliance Officer and management.

Other duties as assigned by the Chief Audit and Compliance Officer from time to time.

Will serve as the Patient Complaints Coordinator, which includes keeping a detailed log of complaints, manager follow up for chart review, contacting the patient, and issuing a recommendations & findings report to the Chief Compliance Officer

Other Duties:
Recalls

Log all recalls that are sent to the hospital

Make sure the recall gets to the appropriate personnel in a timely manner.

Follow-up and make sure the issue has been dealt with and is resolved & log the resolution.

Physician Orders

Responsible for updating, maintaining, and distributing all physician order sets

Qualifications

Education/Certification: High school diploma required, with college degree preferred. Medical background required.

Language/Communication: Must communicate in a timely manner, clearly and effectively, both verbally and in writing.

Mathematical Skills: Competent background in mathematics and statistics is required to perform analyses and compile reports on certain job functions

Mental Capabilities: Work well under pressure. Demonstrates ability to understand and evaluate regulations and guidelines and apply them to the setting of MVH in a manner that will cause the least amount of stress and confusion to the professional staff and patients. Can evaluate suggestions and criticisms objectively and wherever necessary undertakes to change behavior or seek further guidance.

Interpersonal: Demonstrates skills in interpersonal relationships with patients and their families, co-workers, supervisors and management. The ability to influence change without direct authority, and negotiation skills.

Performance: Demonstrates a clear understanding of the highly confidential nature of all facility and patient information and maintains confidentiality of patient information. Demonstrates personal integrity in holding this information in the strictest confidence. Exhibits an attitude, which promotes harmony and goodwill among patients, caregivers, and co-workers. Is self-motivated. Keyboard, word processing and spread sheet computer skills.

PHYSICAL DEMANDS: Intermittent periods of sitting, standing, walking, reaching, and twisting. Occasional need for squatting, bending, and kneeling. Occasionally required to lift and carry up to 10 pounds with some lifting of up to 25 pounds. Requires full range of body motion, manual and finger dexterity and eye-hand coordination there are occasional tasks requiring pulling and pushing of objects up to 25 pounds