Job Description

Job Description:

Southern Jersey Family Medical Centers, Inc. is seeking a Director of Quality Assurance, Clinical Compliance, and Risk Management for a very successful and very busy Federally Qualified Health Center in Southern New Jersey.

Summary: The Director of Performance Improvement and Clinical Compliance "DPICC" ensures compliance with the applicable regulations and requirements of local health departments, the  New Jersey Department of Health, the Federal Office of Inspector General (OIG), and Health Resource and Service Administration (HRSA). The Director ensures that SJFMC adheres to:  all regulations and standards regarding Quality Assurance, HIPAA, organizational policies and procedures, Infection Control, Risk Management, and Employee and Patient Safety.

Position Responsibilities/Duties:

• Ensures that center locations and clinical programs comply with all applicable local, state and federal regulations.
• In conjunction with the Chief Medical Officer and other members of the senior management team, develops, updates and implements the following programs and policies: Quality Assurance, HIPAA , Infection Control, Clinical Protocols, & Center’s Policies and Procedures
• Reviews, investigates, completes and corresponds to external clinical audits and information requests, including but not limit to HEDIS reports and other MCO findings.
• Oversees and coordinates the Risk Management Program which includes reviewing, tracking and trending adverse incidents/events, HIPAA violation complaints, patient and employee safety,  patient complaints, patient satisfaction surveys,  and providing quarterly reports to senior management and the Board of Trustees
• Reviews monthly compliance self-audit checklists for pertinent NJ regulations governing SJFMC programs for all locations and conducts unannounced site visits quarterly.
• Responsible for daily continuous oversight of the Quality Improvement/Quality Assurance program, including ensuring the implementation of QI/QA operating procedures and completion of QI/QA assessments, monitoring QI/QA outcomes, updating QI/QA operating procedures, and providing QA Reports at the QA and Provider Meetings
• Responsible for  coordinating and appropriately implementing modifications to heath center policies and procedures to comply with regulatory changes or to improve quality of care, patient and employee safety, and for developing and implementation of a plan for the mitigation of risk factors as they are identified.
• Develops, reviews and revises, as appropriate, Policies and Procedures, to meet compliance with Standards for Licensure of Ambulatory Care Facilities NJDHS, OIG and HRSA. Evaluates ongoing compliance with Policies and Procedures.
• Ensures compliance with NJDHSS disease and mandatory local, state and federal reporting requirements
  • Develops and implement staff education programs consistent with state, federal and local regulations, including HIPAA, Information Security, NJ Ambulatory Care regulations, Risk Management and Infection Control
  • Ensure that audits are conducted in accordance with an approved schedule according to the centers’ Quality Assurance and Health Care plans
• Manages identified safety issues including patient notifications,  both written and verbal, of unacceptable behaviors resulting in warning and/or discharge from the practice.
• Must be a superuser for the EMR system and work closely with the data analysts to produce accurate quality reports.
• Reviews after-hours calls to ensure appropriate chart documentation and conducts follow-up with providers and the CMO as indicated.
• Attends Board Meetings as directed by the CEO
• Assists CMO with the PEER Review Program
• Represents the organization and participate in external meetings as required.

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Experience and Skills:

Education and Work Experience 

• Masters’ Degree Required
• New Jersey RN License
• Minimum of 3-5 years relevant experience
• Experience in an ambulatory care setting is highly desired

Position Requirements:

• New Jersey RN license
• Must possess MSN or MBA
• Ability to interpret and apply complex regulations
• Strong computer skills
• Clear and concise writing, communications, and presentation skills
• Ability to work independently and proactively under minimal supervision
• Valid driver’s license and reliable transportation for local travel

Southern Jersey Family Medical Centers, Inc. provides a rewarding and challenging work environment, state-of-the-art facilities, and a very competitive benefits package which includes: a healthy work/life balance, generous paid time off, floating /paid holidays, competitive wages, Tuition Assistance Program, 403(b) Retirement Plan with company contribution, Medical, Prescription, Dental, and Life Insurance.

Southern Jersey Family Medical Centers is an Equal Opportunity Employer.

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