Director of Quality and Compliance

Job Description

Responsibilities

Forest View Hospital, located just seven miles southeast of downtown Grand Rapids, Michigan, is a private bed psychiatric facility that serves children, adolescents and adults. We are licensed by the State of Michigan, fully accredited by The Joint Commission and we bring more than years of experience to the evaluation, diagnosis and treatment of a wide range of behavioral health problems. As a part of our continued success and growth, we are seeking qualified applicants for a .

The Director of Quality and Compliance coordinates and guides all employees in interpretation of State, Federal and Managed Care regulatory guidelines and gives assistance on how to attain compliance of regulation. They serve as the facility's primary resource regarding regulatory compliance, and oversees effective implementation of quality and performance improvement processes. This position also acts as the Civil Rights Coordinator. This role will also coordinate compliance with Facility’s responsibilities under Section 7 within its health programs and activities. This includes the investigation of any alleged noncompliance.

Essential Job Responsibilities:

• Ensure facility is up to date on latest quality, regulatory and compliance initiatives
• Policy changes, additions, updates as needed
• Facilitate and respond to all regulatory surveys, investigations, visits, etc
• Routine chart audits for quality improvement and Medical staff OPPE
• Educate workforce on Compliance, Code of Conduct, and Privacy
• Respond to all workforce compliance complaints, investigate and report back to UHS
• Facilitate Quarterly Compliance meetings
• Track data/reporting on various compliance requirements
• Update facility compliance and privacy policies as dictated by UHS
• Schedule and Facilitate monthly Performance Improvement (PI) meeting
• Educate departments about quality improvement processes and opportunities
• Assist with developing plans for auditing, tracking and reporting quality data
• Drives all PI initiatives and maintains awareness of PI plans currently in process
• As Chairperson of PI, this role is also the Chairperson of the Complaints and Grievances Committee (sub-committee to PI) and responds to and investigates complaints/grievances timely, including data tracking
• Acts as Ethics Committee Chairperson
• Receive, review, and process grievances, filed under the grievance Facility’s grievance procedure;
• Coordinate Facility’s recordkeeping requirements;
• Coordinate effective implementation of Facility’s language access procedures;
• Coordinates effective implementation of Facility’s effective communication procedures;
• Coordinate effective implementation of Facility’s reasonable modification procedures;
• Coordinate training of relevant employees, including maintaining documentation required by law.

Benefit Highlights:

• Excellent Medical, Dental, Vision and Prescription Drug Plans
• (K) with company match and discounted stock plan
• Generous Paid Time Off (PTO) of 6. hours biweekly accrued
• Basic Life Insurance of 1x your salary
• Short-Term Disability (STD) and Long-Term Disability (LTD)
• Student Loan Reimbursement Program (Up to $ per month)
• Tuition Reimbursement
• Loan Forgiveness Program
• Pet Insurance and much more

About Universal Health Services

One of the nation’s largest and most respected providers of hospital and healthcare services, Universal Health Services, Inc. (NYSE: UHS) has built an impressive record of achievement and performance. Growing steadily since its inception into an esteemed Fortune corporation, annual revenues were $.8 billion in 4. During the year, UHS was again recognized as one of the World’s Most Admired Companies by Fortune; and listed in Forbes ranking of America’s Largest Public Companies.

Qualifications

Education and Experience Requirements:

• Master’s degree in Psychology, Social Work or related field or RN licensed in the state of Michigan preferred.
• 3 - 5 Years of Psychiatric experience required.
• 3 - 5 Years of Supervisory experience required.
• 3 - 5 years of experience in quality and risk management/improving organizational performance within an acute medical or psychiatric treatment setting.
• A strong knowledge of JOINT COMMISSION, TDSHS, CMS standards, and any other applicable federal and state laws and regulations governing mental health care facilities.
• Possesses ability to identify and analyze problems collect data, establish facts, and draw valid conclusions.
• Possess knowledge of risk identification and prevention techniques.
• Effective administrative and management skills.
• Proficient with Root Cause Analysis methodology.
• Knowledge of healthcare facility operations, functions, and staffing requirements.
• Knowledge of medical/professional staff by-laws and governing board issues.
• Knowledge of insurance and loss control theory and practice in a healthcare environment.
• Knowledge and understanding of the principles and procedures for the investigation and processing of professional liability/ medical malpractice claims.
• Ability to use independent judgment and to manage and impart confidential information.