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Director of Quality, Compliance & Education (RN)

Company: DeKalb Health
Location: Manchester
Posted on: January 7, 2022

Job Description:

Director of Quality, Compliance & Education (RN), Manchester General Information Job Title: Director of Quality, Compliance & Education (RN) Location: 145 Hollis St Manchester, NH, 03101 United States Employee Type: Full-Time Job Category: Administrative 6 Years 8 Years Required Degree: 4 Year Degree Manage Others: Yes Description Reporting to the CNO/CCO, the Director of Quality, Compliance and Education is the lead for three primary areas/functions: -
1) QUALITY: Works in collaboration with the CMO to implement quality improvement initiatives across the health center infrastructure, including certifications in programs like NCQA's Patient Center Medical Home
2) COMPLIANCE: the coordination of compliance activities and risk management activities to assure adhesion to HRSA Compliance regulations and other regulatory bodies, including state and federal regulation, in collaboration with other leaders in key areas, and
3) EDUCATION: the coordination of education for both patients and staff. - JOB RELATIONSHIPS:

  • Responsible to the Chief Nursing Officer but works closely with the rest of the clinical leadership team, and staff at all levels.
  • Coordination of Patient Education programs such as the Breast & Cervical Cancer Screening Program (BCCP), Diabetic Education, and Nutrition.
  • Oversees the following individuals: Staff Educator, Health Care Data Manager, BCCP Program Coordinator, Diabetic Educator, and Nutritionists. RESPONSIBILITIES & AUTHORITIES: 1) PRIMARY QUALITY FUNCTIONS: a) Works closely with CMO to oversee the implementation of the annual QI Performance plan b) Participates on the QI Committee and co-chairs with the CMO c) Works with the Health Care Data Manager to monitor trends in quality measures, shares this data with the CNO, CMO and CEO, and other managers who have responsibility for various areas impacted d) Designs educational forums/trainings and materials to support staff education around quality metrics and outcomes monitoring e) Reviews payor reports on QI programs and assist with development of response plans to areas where we are not functioning at an expected level, in collaboration with CNO, CMO and CEO. f) Participate in the Quality Improvement Committee, to include working with the Chief Medical Officer to establish clinical goals and design methodology for assessing progress towards those goals, including working with EMR/Business Objects/Crystal Reports to develop guidelines and reports to capture such data. g) Responsible for adherence to state and other contracted agreements for Quality related activities, including UDS, Payor agreements, State of NH contracts such as Primary care, and other agreements defining specific quality expectations. 2) PRIMARY COMPLIANCE FUNCTIONS: a) Co-Facilitate the EOC Committee, to include oversight of compliance with regulatory expectations of State mandates as well as clinical recommendations from OSHA, CDC and related organizations. b) Co-Facilitate the Compliance Committee along with the designated Board Chair of the Committee. Oversee that other leaders are completing their areas of responsibility in Compliance. Provide regular updates to the Board of Directors and leadership team. c) Develops and maintains up-to-date knowledge of corporate compliance requirements and related laws and regulations as mandated or recommended by OIG, CMS, and other agencies; attends outside corporate compliance trainings provided by NACHC and/or other agencies as directed by the CEO d) Oversees a corporate wide risk management program, develops and maintains a written corporate risk management plan and annual evaluation of the plans' effectiveness. e) In consultation with the CEO, submits mandatory notification of known or suspected corporate compliance violations to the appropriate regulatory agencies. f) Serves as a resource for the Chief Nursing Officer for all external and internal compliance audits; ensures that corrective action plans are documented in a timely manner and effectively implemented. g) Develops and maintains policies and procedures related to the corporate compliance program including risk-management. h) Prepares for FTCA on an annual basis, monitors FTCA related activities, manages acute issues identified as needing FTCA involvement, related policies, procedures and staff education. 3) PRIMARY EDUCATION FUNCTIONS: a) Establish and maintain a system of health education for Amoskeag Health, to include educational materials, developing healthcare contacts in the community and acting as a liaison with agencies. b) Develop linkages with medical, behavioral/social and other community agencies to provide Patient educational materials, speakers, etc. c) Develop individual and group education classes, to include staff in-services. Assist other disciplines to do basic healthcare education within their particular areas of interest and expertise. d) Ensure that staff has knowledge and materials necessary to perform patient education. Works in tandem with nutritionist, diabetic educator and others as needed to identify gaps in patient education and research resources to fill in those gaps. e) Oversee training for clinical staff, which may include orientation to new clinical functions such as equipment, or ongoing training in specific areas such as immunizations and refugee issues (examples only). f) Oversee training for non-clinical staff, including orientation to the EMR, the scheduling system, and other related work flows, procedures, and compliance related educational activities. 4) SECONDARY FUNCTIONS: This individual will be cross-trained to assist the nursing staff within the facility in the event of a staff shortage. Although this would be limited to urgent situations or significant shortages, it is the expectation that this individual would be trained in the most rudimentary functions of the clinical roles for emergency coverage and to make sure they know what the various positions are expected to do so that their educational priorities are well known to the Director. 5) Provide clear written and oral communication to Amoskeag Health patients, families and employees. 6) Maintain accurate, timely documentation in the client's electronic health record of client contacts, case planning, and client's plan of care. All documentation in a client's record to be easily understood by anyone who may need to access the medical record. 7) Maintain records of individual staff attendance at in-house education and at outside seminars. Provide yearly summary of education to Senior Management and copy of education record to individual staff. 8) Attend and participate in other Amoskeag Health meetings as directed. If absent, responsible for reading minutes of meetings and signing the documentation. 9) Present mandatory safety-related in-services as designated by Senior Management. 10) Maintain licensure for current RN status by ongoing professional education. 11) Sensitivity to cultural diversity of population being served. 12) Other responsibilities as assigned by supervisor. KNOWLEDGE/SKILLS/ABILITIES: In addition, individual must possess these knowledge and these skills and abilities or be able to explain and demonstrate that the individual can perform the primary functions of the job with or without reasonable accommodation using some other combination of skills and abilities and to posses the necessary physical requirements with or without the aid of mechanical devices to safely perform the primary functions of the job.
    • Physical requirements include ability to extend hand(s) and arm(s) in any direction; pick, pinch, type or otherwise work primarily with fingers; stand for sustained periods of time and move about on foot to accomplish tasks, raise objects from a lower to a higher position or move objects horizontally from position to position; apply pressure to an object with fingertips; sustain substantial movement of wrists, hands and/or fingertips. -
    • Ability to express or exchange ideas by means of the spoken word. -
    • Ability to receive detailed information through oral communication and make fine discrimination in sound. -
    • Ability to interact effectively with people of varied educational, socioeconomic and ethnic backgrounds, skill levels and value systems; to work with frequent interruptions and to respond appropriately to unexpected situations. Excellent listening skills. -
    • Ability to exert up to twenty (20) pounds of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, punch, pull, or otherwise move objects. Primary functions involve sitting, as well as stooping, kneeling, crouching, and reaching; walking, particularly for long distances, and standing for sustained periods of time. -
    • Visual acuity sufficient for work which deals largely with visual inspection involving small anatomical or physiological details as well as the whole patient, preparing and analyzing data and figures, accounting, computer terminal operation, extensive reading, and visual inspection involving small parts/defects. -
    • Excellent written, verbal communication and social skills. -dent and policy. q Requires the ability to plan and perform difficult work where only general methods are available. Involves highly technical or involved projects, presenting new or constantly changing problems. Requires outstanding judgment and initiative in dealing with complex factors not easily evaluated, also making decisions for which there is little precedent. q Requires the ability to plan and perform complex work that involves new or constantly changing problems where there is little accepted method or procedure. Involves participation in the formulation and carrying out of policies, objectives and programs for major divisions or functions. Considerable ingenuity and exceptional judgment required to deal with factors not easily evaluated, interpret results and make decisions carrying a great deal of responsibility. Direct and coordinate the work of subordinate supervision in order to attain objectives. QUALIFICATIONS:
      • Education/Training/Licensure: BSN minimum, additional education in areas of responsibility preferred (but not required), such as an MBA in Healthcare Administration, or an MSN. Current New Hampshire RN License.
      • Experience: Community health center experience preferred. RN with at least three years of experience in direct services and 3-5 years of experience in a management role with progressive responsibilities. A good candidate will have experience in the areas of the role, specifically with quality improvement, accreditation, education, compliance or related experience. BSN preferred. -
      • Knowledge/Skills: Ability to delegate tasks to other team members. Basic computer skills to utilize software tracking systems. Summary WHY EMPLOYEES CHOOSE AMOSKEAG HEALTH
        • A challenging and exciting team-focused environment
        • Competitive compensation and benefit package (Health, Dental, Vision)
        • A healthy work-life balance and flexible hours
        • Focus on employee engagement and career development

          WHO WE ARE, WHAT WE DO Amoskeag Health, a Federally Qualified Health Center (FQHC) and progressive, nonprofit primary healthcare organization that -celebrated its 25th -year in 2018.
          Our team of healthcare professionals positively impacts the health, well-being and quality of life for those we serve providing comprehensive, integrated, affordable healthcare and education to patients. We utilize a team-based model including embedded Behavioral Health Clinicians as well as Case Managers, Care Coordinators and Community Health Workers. Amoskeag Health requires all employees to show proof of vaccination for both COVID 19 and annual influenza (or show a valid religious, pregnancy, or disability-related reason for not being vaccinated).

Keywords: DeKalb Health, Manchester , Director of Quality, Compliance & Education (RN), Executive , Manchester, New Hampshire

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