Position Summary: Develops, organizes and monitors a Quality Assessment and Performance Improvement Plan (QAPI) for the Lutheran Senior Healthcare program. The Director of Quality Assurance in conjunction with the Medical Director is responsible for developing the QAPI annual plan, and guiding the implementation of the plan. Ensures that data is collected from all appropriate sources; and the data is examined and the results are shared with all stakeholders. Oversees the process to evaluate and resolve medical and non-medical grievances by participants, their family members, or representatives. The Director of Quality Assurance acts as the Compliance and (HIPAA) Privacy Officer for Lutheran Senior Healthcare. The Director of Quality Assurance is responsible for over sight of the Medical Record Clerk and the Compliance and Privacy Officer to ensure all CMS and State required activities related with these positions are accomplished.
- Develops, and guides the implementation of the annual QAPI Plan. Collaborate with the Medical Director and Executive Director in development of the annual QAPI plan.
- Review, revise and communicate the QAPI plan to participants, staff, contractors, administration, participant advisory committee and the Board. Send the annual QAPI Plan to appropriate state and federal agencies.
- Ensures staff integration into the QAPI process through Continuous Quality Improvement education and developing opportunities for input.
- Analyses of risk management data, and quality assessment performance improvement activities data with the objective of identifying and controlling loss to protect the assets of the organization.
- Has overall responsibility for the Medicare Part D fraud, waste and abuse Compliance Program. Ensures that the Compliance and Privacy Officer completes the activities and responsibilities identified in the Compliance program and those activities and responsibilities related to the HIPAA privacy rule.
- Supervises the Medical Records Clerk and functions, assuring that all documentation requirements are met and that records and data of all types are maintained appropriately and retained for the requisite periods of time.
- Write/compile the Annual QAPI Report at the end of the fiscal (calendar) year, review it with the Medical Director and Executive Director, and share it with to participants, staff, contractors, and administration, the participant advisory council and the Board. Send the annual QAPI Report to appropriate state and federal agencies.
- Develop, monitor, and report on PACE Health Plan Management System (HPMS) quality indicators. Prepare presentation of quality improvement for quarterly Quality Care Team.
- Oversees the process to evaluate, and resolve medical and non-medical grievances by participants, and or their representatives, ensures information is reviewed for incorporating issues in development of Quality improvement initiatives and annual QAPI plan.
- Attend quarterly participant advisory committee meetings and, staff meetings and report on QAPI.
- Integrate QAPI into orientation and training for new staff.
- Facilitate QAPI meetings to ensure that the developed plan is successfully installed and maintained.
- Assist senior staff and mid level managers with establishing process evaluation and performance improvement initiatives using PDCA (Plan, Do, Study, Act) in their area of responsibility. Help staff identify problems and facilitate their problem resolution efforts.
- Acts as the PACE Compliance and Privacy (HIPAA) Officer and provides initial training to new hires, and ongoing training to existing staff and contract organizations.
- Trains managers and supervisors in essential monitoring methods and measurement techniques specific to quality indicators.
- Develop, implement, and analyze quality studies and quality surveys.
- Coordinate internal audits and corrective action plans with required administrative staff.
- Stay abreast of new developments (e.g. HPMS, other), report to Executive Director and recommend changes in policies, procedures, forms as appropriate.
- Develop and implement a program of staff development and in-service training to meet regulatory requirements and organizational needs within available resources.
- Maintain documentation of staff development and in- service training in compliance with standards and regulatory requirements.
- Oversee compliance with all applicable regulatory, contractual standards.
- Develop schedules for required periodic compliance activities, monitor implementation, analyze and report on adherence.
- Recommend corrective action plans to Executive Director, and oversee executive management team activities to implement approved corrective action plans.
- Manage preparations for site visits and inspections.
- Manage ad hoc and special projects assigned by Executive Director.
- Participate as a fully contributing member of the PACE management team, participating in meetings, contributing to strategic plan, supporting the decisions of the management team.
- Participate in formulation and maintenance of PACE policies and procedures.
- Perform other related duties as required.
Experience and Skills
- RN License - New Jersey or Minimum of Bachelors Degree in health related field or five (5) years of relevant experience in health related field.
- Current driver's license and proof of auto insurance
- Knowledge of quality management techniques and methods that measure and improve services.
- Knowledge of compliance and privacy laws and regulations that effect health care systems.
- Ability to coordinate and effectively lead groups.
- Ability to work in an interdisciplinary team and multi-ethnic community.
- Good educator who is willing to share information and serve as a mentor.
- Ability to bridge the communication and technical gap with diverse individuals
- Self starter with strong organizational and time management skills.
- Strong analytical skills, detail oriented, extremely well organized and able to plan and problem solve
- Computer literate (MS Word, Excel, Access, Outlook)
- Excellent written and oral communication skills.
- Strong leadership abilities.
- Experience in compliance and privacy (HIPAA) activities
- Minimum of 1 year working with the frail or elderly
- Employees must have medical clearance for communicable diseases and up-to-date immunizations before having direct participant contact.
Lutheran Social Ministries of NJ - 17 months ago
Built on more than a century of grace-filled service, Lutheran Social Ministries of New Jersey (LSMNJ) continues its mission as a...