Healthcare Quality and Compliance Manager

Job description

Job Summary:

In addition to the responsibilities listed below, this role is also responsible for: independently scheduling andperforming the Department of Health Care Services (DHCS) Facility Site Reviews (FSR), Medical Record Reviews (MRR), and Physical Accessibility Review (PAR) surveys as assigned; ensuring all FSR surveys are conducted in accordance with DHCS Managed Care Quality and Monitoring Division requirements; reporting FSR findings to all relevant providers, departments, and managers; overseeing the submission of FSR/MRR/PARs to relevant leaders; issuing corrective action plans and ensuring corrective plans are closed in alignment with DHCS standards and timelines; and attending required FSR trainings to maintain Site Reviewer certification.

Essential Responsibilities:

• Promotes learning in others by communicating information and providing advice to drive projects forward; builds relationships with cross-functional stakeholders. Listens, responds to, seeks, and addresses performance feedback; provides actionable feedback to others, including upward feedback to leadership and mentors junior team members. Practices self-leadership; creates and executes plans to capitalize on strengths and improve opportunity areas; influences team members within assigned team or unit. Adapts to competing demands and new responsibilities; adapts to and learns from change, challenges, and feedback. Models team collaboration within and across teams.
• Conducts or oversees business-specific projects by applying deep expertise in subject area; promotes adherence to all procedures and policies. Partners internally and externally to make effective business decisions; determines and carries out processes and methodologies; solves complex problems; escalates high-priority issues or risks, as appropriate; monitors progress and results. Develops work plans to meet business priorities and deadlines; coordinates and delegates resources to accomplish organizational goals. Recognizes and capitalizes on improvement opportunities; evaluates recommendations made; influences the completion of project tasks by others.
• Serves as the subject matter expert for regulations projects/committees, and internal stakeholders by: providing consultation on the interpretation and interaction of current policies, and how they interact with the current climate, and potential changes to regulations and legislation; serving as a technical advisor on committees and projects to drive development of policies or procedures for regulations and auditing processes; developing complex content and delivering tailored educational programs to align organizational policies and procedures with regulatory requirements; and anticipating and weighing practical/technical considerations in addressing issues and coordinating with the appropriate stakeholders to develop resolutions.
• Develops data management and reporting processes by: entering complex practitioner/provider data and conducts data cleaning as needed; and entering, analyzing, and independently drafting and reviewing action plans/recommendations required data into appropriate databases.
• Ensures licensing and accreditation by: independently reviewing and guiding others to review requirements for new, existing, and expanding facilities/services to aid in achievement of compliance with state, federal, and accrediting standards; consulting with other departments to ensure certification for complex cases; and independently conducting a widely impactful and detailed gap analysis and mentoring others to identify services renewals and planning to ensure services are compliant.
• Identifies and recommends improvements to processes of responding to regulatory audits and survey preparedness efforts by: independently enacting complex reporting, keeping current on regulatory requirements, and guiding others to do the same in preparation for surveys (e.g., NCQA, Joint Commission, AAAHC); serving as liaison between external evaluators, vendors, and senior stakeholders to facilitate on-site visits and evaluations; independently conducting, reviewing, evaluating upon site visit criteria, and performing site visits as appropriate to ensure survey readiness; delivering requested complex audit documentation, information, and reports; assessing the workflow of auditing surveys to identify gaps in completion and reporting, focusing on high vulnerability areas; facilitating educational forums, conducting routine audits, and leading mock surveys within departments to ensure auditing and survey preparedness tracking, trending, and facilitating the development of high impact corrective action plans (CAP) as necessary in collaboration with applicable departments to assure site visit compliance; and leading the collaborations with other departments (e.g., Revenue Cycle), gathering documents and data to support the timely completion of the annual state/federal/regulatory body reporting as required.

Qualifications:

Minimum Qualifications:

• Minimum two (2) years of experience as a DHCS Managed Care Quality and Monitoring Division (MCQMD) Certified Site Reviewer or MCQMD Certified Master Trainer.
• Minimum three (3) years of experience in a leadership role with or without direct reports.
• Minimum three (3) years of experience with databases and spreadsheets.
• Bachelors degree in Business Administration, Health Care Administration, Nursing, Public Health, or related field AND minimum seven (7) years of experience in health care operations, quality, risk management, hospital environment, or a directly related field OR minimum ten (10) years of experience in health care operations, quality, risk management, hospital environment, or a directly related field.

• MCQMD Certified Master Trainer (California) OR MCQMD Certified Site Reviewer (California)

• Doctor of Medicine License (California) OR Registered Nurse License (California) OR Physician Assistant License (California) OR Nurse Practitioner Certificate (California)