Quality Assurance- Manager of Regulatory, QA, and Risk FT/Day

JOB SUMMARY

The Manager of Regulatory, QA, and Risk Management works collaboratively with senior leadership, MMHS leaders, physicians and staff to reduce risk and promote quality patient care and safety. This is accomplished through various assessment activities and process improvement actions through the monthly Quality/Patient Safety Committee/Committee of the whole or ad hoc meetings. Manages and coordinates efforts to ensure that quality management programs are developed and managed using a data driven focus and sets priorities for improvements aligned to ongoing strategic imperatives. Ensures compliance with Federal healthcare program requirements and facility's risk management activities, which include coordinating insurance coverage and risk financing, managing claims against the facility, interfacing with defense legal counsel, administering the risk management program on a management education programs and complying with the Joint Commissions risk management standards, all the objective of controlling and minimizing loss to protect the assets of the facility. This position exists 1) as a channel of communication to receive and direct compliance issues to appropriate MMHS resources for investigation and resolution, and 2) as an internal resource with which concerned parties may communicate after other formal channels and resources have been exhausted. Will work closely with other management who are responsible for ensuring the organization complies with Joint Commission, Health Insurance Portability and Accountability Act (HIPAA), and applicable accreditation standards. Revised 12.20.2024PERFORMANCE

DIMENSIONS AND

TASKSEssential Function1. On-going assessments of regulatory, quality assurance, and risk management, compliance policies and procedures and assist in updating or developing new policies to enhance this positions' areas of operations.2. Carry out a vulnerability analysis on the organization's Regulatory, QA, and Risk programs and activities, discover areas of potential risk and vulnerability, and create and implement solutions to eliminate the potential risks. 3. Develop and implement quality improvement initiatives.4. Develop action plans and track progress.5. Train staff on quality improvement processes.6. Manage and direct healthcare training and educational programs to advance awareness and education of potential Quality, Compliance risks, vulnerability, and reporting. 7. Supervise training in other laws such as the Physician Payment Sunshine Act, HIPAA, Stark Laws, and related state/federal laws to ensure employees are informed on ethical and legal standards.8. Tracks, reports and ensures the completion of action items resulting from compliance reviews. Analyzes and investigates serious safety events in support of the patient safety program.9. Conduct or delegate investigations, and coordinate internal and external corrective measures to be executed. 10. Establishes and maintains a mechanism to track access to regulatory and risk information, within the purview of the organization and as required by law to allow qualified individuals to review or receive a report on such activities. 11. Stay informed of current legislation and enforcement issues affecting the healthcare industry, as well as Regulatory, QA, and Risk Management best practices. 12. Prepare report for management on incidents, investigations, and all significant "breach" Regulatory, QA, and Risk issues. 13. Carry out due diligence on new healthcare businesses/service before they are implemented and design effective Regulatory, QA, and Risk integration plans. 14. Accurately, timely, and with due diligence will assist in the preparation and presentations for Joint Commission and other related surveys reflecting compliance to clinical and non-clinical integration of standards. Identifies deficiencies and assist in remedial resolution of such. 15. Responds to complaints and claims related to professional liability and transmits that information to the insurance carrier of legal counsel. At the request of management, legal counsel, or the adjuster, participates in responding to the complaint or claim to obtain information and facilitate settlement at an early stage. Works in coordination with patient ombudsman or acts as same to resolve complaints before they develop into professional liability claims. 16. Receives incident reports and other information regarding untoward occurrences in the facility, such as quality assurance outline or variations, and collates such information systematically to permit analysis pursuant to risk management policy and procedure. Reviews collated data to identify trends regarding accidents or occurrences, and recommends corrective action to management if appropriate. Prepares reports to management regarding data systems and findings. 17. All other duties as assigned