Claims Quality Audit Director jobs in New Bedford, MA

The Director of Quality, Compliance and Risk requires a high degree of autonomy. This role provides oversight of all Compliance, Quality Assurance, and Risk Management initiatives. The Director investigates causes, diversions, and variations from practices. This role is responsible for the process of quality improvement efforts focusing on clinical quality, reviewing performance measures, and addressing patient complaints. In this role the Director serves as the champion of constant improvement.

 ESSENTIAL DUTIES AND RESPONSIBILITIES include the following:

1. The Director of Quality, Compliance and Risk promotes an environment in which the healthcare team can work cooperatively toward achieving departmental and facility goals and objectives.
2. Responsible for identifying and supporting best practices throughout the organization.
3. The Director of Quality, Compliance and Risk manages risk by assuring agency follows, and factually interpretates all federal, state, and local laws, rules, and regulations including CMS Conditions of Participation, BSAS, Joint Commission and HRSA
4. Director prepares the agency for survey readiness by conducting survey activities and functioning as a Survey Coordinator along with other team members during surveys.
5. Assist with the development and monitoring of corrective action plans for regulatory statements and PI improvements.
6. The Director of Quality, Compliance and Risk maintain quality and outcome data and uses the data to identify opportunities for improvement.
7. Reviews all event reports and notifies management of any incidents of high-risk significance followed by an intensive investigation and preparation of a root cause analysis.
8. The Director of Quality, Compliance and Risk assists the CIO in the management of EHR and other data collection platforms as it applies to user compliance and quality outcomes.
9. Responsible for the maintenance, development and monitoring of all facility-wide policies and procedures.
10. The Director of Quality, Compliance and Risk monitors and reports on the effectiveness of services through Performance Improvement, KPI’s and other data collection methods.
11. Promotes a planned and systematic approach to Quality with the least amount of duplication and in the most cost-efficient manner.
12. Educates and trains Administration, Medical Staff, and employees on a full scope of PI Initiatives and their roles in performance improvement.
13. Oversees and works collaboratively with directors on all data collection and reporting processes.
14. Collects data, reviews, and reports all adverse incidents.
15. Coordinates principals to gather information related to patient complaints to ensure they are resolved and prepares written responses to patients. Trends complaints and provides meaningful insight for process or procedural improvements.
16. Coordinate and facilitate all SSTAR licensing and accreditation reviews.
17. Reviews/advises on proposed legislative and regulatory changes. Drafts comments/responses as requested.
18. Serves in the leadership for responding to Patient Grievances and the development of P&P.
19. Responsible for providing meaningful feedback to departments, committees, and Medical Staff on a regular basis and timely manner. Demonstrates tact and discretion in this communication.
20. Will assume leadership/administrative responsibility for the coordination of or participating in the preparation of grant proposals.
21. Assists directors in the writing and updating of all policies and procedures.
22. Functions as a liaison, ensuring cooperation and effective interdepartmental relations as it relates to QA/PI.
23. Participates with Senior Leadership in the planning and development of programs as requested.
24. Chairs both the Risk Management and Compliance Committees and serves on the Performance Improvement Committee. Prepares quarterly and annual Board Reports.
25. Develop and maintain effective working relationships with outside agencies and departments.
26. Assists CEO and Directors with oversight supervision of contracted services.
27. Attends networking and educational opportunities for personal and organizational development.
28. Assists the CEO with non-payer facility contracting issues including securing Business Associate Agreements.
29. Other duties as assigned.

SUPERVISORY RESPONSIBILITY

None

QUALIFICATIONS

Masters preferred.  Bachelor’s Degree in Business/Healthcare Administration, Statistical Analysis, Quality Management, or related field,

EDUCATION, EXPERIENCE, & SKILLS

• Healthcare Compliance Certification preferred.
• Minimum of 5 years’ experience in quality/process improvement with a minimum of 4 years in the healthcare or SUD treatment field. Previous quality assurance, compliance and performance improvement experience required as well as experience working with regulatory/licensing authorities.
• Strong analytical and computer skills.
• Must be able to meet deadlines and managing multiple tasks adapting to shifts in priorities.
• Strong written and verbal skills

• 403B
• Dental insurance
• Disability insurance through Massachusetts PFML
• Employee discounts, cell phone, eyewear etc.
• Health insurance
• Life insurance
• Paid time off
• Vision insurance
• Flexible Spending Account
• Opportunities to earn CEU's
• Voluntary Benefits including Term and Whole Life, Accident, Critical Illness and Disability.