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Director Post-acute Care Quality And Compliance

Master's Degree Preferred
Serves as an expert for post-acute care in accreditation, compliance and regulatory topics and provides guidance and leadership in quality and safety initiatives, and compliance strategies. Facilitates a continuous state of readiness surrounding licensure, accreditation and certification programs to ensure compliance with state and federal rules and regulations for Covenant facilities. Supports the coordination of regulatory compliance activities that include assessment of standards compliance, survey preparation and survey follow-up. Provides consultation to Covenant managed and affiliated organizations as required.
Job Responsibilities
The Director of Post-Acute Care Quality and Compliance researches and maintains compliance and accreditation requirement expertise, including standards, Conditions of Participation, and regulations.
Scans the regulatory environment to ensure that Covenant is operating with the most current and relevant information. Distills the applicable information and provides guidance and interpretation to internal and external customers on current regulatory requirements, readiness standards updates, and other accreditation readiness education strategies.
Facilitates compliance with federal, state, and local regulatory requirements as well as additional certifications and awards, and assists Covenant organizations in survey preparation.
Represents Covenant Health Systems as appropriate in designated public, regulatory and accreditation programs.
Provides support to facilities interested in developing specialized programs or services and/or creating specialized care capacity.
Promotes quality, safety, and performance improvement throughout the organization.
Coordinates quality and safety metric reporting to Covenant Health Systems.
Provides management reports/updates on emerging compliance and regulatory issues.
Supports the Vice President of Quality and Safety in quality improvement and patient safety initiatives, including survey development and administration, tool development, data analysis, and dashboards, and reporting.
Reviews identified accreditation, licensing and certification survey reports in a timely manner, and provides assistance with correction and action plan development. Notifies and collaborates with Covenant Legal and Risk resources as required.
Serves as a resource to Covenant's Clinical Transformation Committee to ensure the best evidence based and cost-effective practices system-wide.
Collaborates with internal partners to provide support for initiatives such as value-based purchasing, clinically-related group purchasing arrangements, or out-sourced clinical/ professional services.
Serves as a resource for EHR standardization and documentation.
Regular travel to Covenant's post-acute care facilities.
Participates in and provides support for additional Covenant Committees, as requested.
Abides by the Standards of Conduct which are the basis for the Organizational Integrity Program.
Supports and promotes the mission and values of Covenant Health Systems and the Catholic Health Ministry.
Position requires travel to the post acute care facilities located throughout New England.
Job Requirements
Bachelor's degree in Nursing or clinical discipline preferred.
A minimum of 7 years experience in health care management, with experience in Quality, Risk, Patient Safety or Regulatory Compliance.
Demonstrated understanding of regulatory affairs, quality improvement functions and principles.
Knowledge and experience with performance improvement tools and techniques, including Lean.
Proficiency in Microsoft Office suite - Word, Excel, PowerPoint, and Outlook
Demonstrated success working in a team environment, with strong communication skills and proven ability to create strong, effective working relationships.
Current and unrestricted clinical license (if applicable).
Certified Professional in Healthcare Quality (CPHQ) preferred.
Ability to set priorities, meet deadlines, and work independently without close supervision.
We are an equal opportunity, affirmative action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, age, disability status, gender, sexual orientation, ancestry, protected veteran status, national origin, genetic information or any other legally protected status.


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