Director Quality and Compliance - Hospice Spartanburg Regional Healthcare System - 3.8 Drayton, SC Job Details Full-time 1 day ago Qualifications RN License Hospice experience Bachelor's degree Hospice & palliative medicine Full Job Description Job Requirements We are hiring a Director of Quality and Compliance to join our Hospice Team! The Director of Quality and Compliance is appointed by the Governing Body and assumes responsibility for planning, directing, managing, and facilitating the Quality and Compliance Programs for the Hospice Program. The Director ensures that the policies and procedures, and QAPI plans comply with federal, state, and local laws, regulations, codes, and current practice standards, is responsible for overseeing the identification and assessment of compliance vulnerability and risk. The Hospice's QAPI program includes but is not limited to oversight and responsibility for reports going to the governing body. The Director is responsible for the compliance training and education for all levels of personnel, conducts and oversees audits of defined areas/functions to assess compliance, oversees implementation action/resolution to problems or misconduct. The Director acts as an internal quality consultant and subject matter expert in process improvement, clinical risk management, Consumer Assessment of Healthcare Providers & Systems review and project management. The Director is responsible for discovering opportunities for improvement through data mining/analysis and observation of processes of care. The Director collaborates across internal and external resources and disciplines to identify opportunities to improve efficiencies utilizing Lean/Six Sigma principles and other quality improvement tools to positively impact and achieve sustainable results that support strategic goals. The Director acts as a resource and is responsible for summarizing findings of quality initiatives for outcomes reporting in addition to synthesizing current evidence-based research to apply to quality programs and process improvement teams. The Director also mentors and orients managers and staff to aspects of quality, project management, and process improvement. The Director supports the program to maintain an environment of continuous survey readiness. The Director has the delegated authority to take immediate and appropriate action in the event of an emergency where there is clear and present danger that poses a threat of personal injury, or threat of damage to property or equipment. The Director assures financial and regulatory compliance while working collaboratively with the Director of Nursing and Clinical Services and the Hospice Administrator. The Director of Quality and Compliance will step in as Administrator on Call in the absence of the Hospice Administrator and the Director of Nursing. Minimum Requirements Education Bachelor's Degree in Nursing or Related Field. Experience 5 years RN experience, 2 years of which are Hospice experience License/Registration/Certifications Current, Unrestricted License related to Degree Preferred Requirements Preferred Education Master's Degree in Nursing, Master's Degree in Related Field Preferred Experience 2-3 years management experience, 5 years healthcare experience, 2 years regulatory and/or data analysis experience preferred. 3-5 Years Hospice Experience Preferred License/Registration/Certifications Current, Unrestricted Registered Nursing License Core Job Responsibilities Data collection and analysis, performance improvement. Chairperson for all Quality Committees for Hospice. Resource for all other related committees. Prepare reports for internal and external submission and review. Oversight of Additional Documentation Request process and compliance. Oversight of Hospice Item Set submission to the Center for Medicare Services. Oversight of Accreditation Commission for Health Care Accreditation Review and follow-up action for Incidence and Patient Relation entries for Hospice. Regulatory readiness for all locations - Hospice Home, Drayton, and Contracted Entities outside of SRHS. Timely submission of reportable variances and plan of correction to DHEC and other regulatory agencies. Compliance regarding record maintenance and legacy documents/systems. Other duties as assigned Must be able to withstand long hours of standing, walking, sitting, stooping, and bending. Manual dexterity, good eye/hand coordination, acceptable vision, and hearing needed in daily work. Sit and view computer monitor for extended periods of time.