Director of Quality and Compliance

Responsibilities

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Forest View Hospital, located just seven miles southeast of downtown Grand Rapids, Michigan, is a private 108 bed psychiatric facility that serves children, adolescents and adults.

We are licensed by the State of Michigan, fully accredited by The Joint Commission and we bring more than 45 years of experience to the evaluation, diagnosis and treatment of a wide range of behavioral health problems.

As a part of our continued success and growth, we are seeking a Director of Quality and Compliance .

The Director of Quality and Compliance coordinates and guides all employees in interpretation of State, Federal and Managed Care regulatory guidelines and gives assistance on how to attain compliance of regulation.

They serve as the facility's primary resource regarding regulatory compliance, and oversees effective implementation of quality and performance improvement processes.

Key Job Duties and Responsibilities :

• Ensure facility is up to date on latest quality, regulatory and compliance initiatives
• Policy changes, additions, updates as needed
• Facilitate and respond to all regulatory surveys, investigations, visits, etc.
• Routine chart audits for quality improvement and Medical staff OPPE
• Educate workforce on Compliance, Code of Conduct, and Privacy
• Respond to all workforce compliance complaints, investigate and report back to UHS
• Facilitate Quarterly Compliance meetings
• Track data / reporting on various compliance requirements
• Update facility compliance and privacy policies as dictated by UHS
• Schedule and Facilitate monthly Performance Improvement (PI) meeting
• Educate departments about quality improvement processes and opportunities
• Assist with developing plans for auditing, tracking and reporting quality data
• As Chairperson of PI, this role is also the Chairperson of the Complaints and Grievances Committee (sub-committee to PI) and responds to and investigates complaints / grievances timely, including data tracking
• Acts as Ethics Committee Chairperson

Qualifications :

• Master's degree in Psychology, Social Work or related field or RN licensed in the state of Michigan.
• 3 - 5 Years of Psychiatric experience required.
• 3 - 5 Years of Supervisory experience required.
• 3 - 5 years of experience in quality and risk management / improving organizational performance within an acute medical or psychiatric treatment setting.
• A strong knowledge of JOINT COMMISSION, TDSHS, CMS standards, and any other applicable federal and state laws and regulations governing mental health care facilities.

Required Skills :

• Possesses ability to identify and analyze problems collect data, establish facts, and draw valid conclusions.
• Possess knowledge of risk identification and prevention techniques.
• Effective administrative and management skills.
• Proficient with Root Cause Analysis methodology.
• Knowledge of healthcare facility operations, functions, and staffing requirements.
• Knowledge of medical / professional staff by-laws and governing board issues.
• Knowledge of insurance and loss control theory and practice in a healthcare environment.
• Knowledge and understanding of the principles and procedures for the investigation and processing of professional liability / medical malpractice claims.
• Ability to use independent judgment and to manage and impart confidential information.

EEO Statement :

Forest View Hospital is committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates.

Forest View Hospital is an equal opportunity employer and as such, openly supports and fully commits to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws.

We believe that diversity and inclusion among our teammates is critical to our success.

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