Director of Corporate Compliance and Quality

US-CA-Hayward
Job ID
2017-1132
HAYWARD -HWD
Category
Administration
Type
Regular Full-Time

Overview

Tiburcio Vasquez Health Center (TVHC) is a leading nonprofit community health center that has provided comprehensive medical, dental, and mental health care since 1971 that primarily serves the community's underserved population. TVHC is located in Hayward, California and is part of the beautiful San Francisco East Bay area.

 

As the primary lead in charge of TVHC's compliance programs and in support of quality assurance and improvement measures, this position works under the supervision of the Executive Vice President/Chief Administrative Officer.


The position develops and oversees a system for uniform handling of violations in Standards of Care, regulations, policies, protocols and procedures, by conducting root-cause analysis and following notice requirements where applicable.  Specifically the position is responsible for regular, ongoing assessment in areas of key performance for operations, measuring against established standards for quality and compliance, providing timely and efficient reporting to management and parties accountable within the organization. 

 

This role will have significant responsibility for TVHC’s pursuit of operational and clinical improvements as it impacts quality and safety of care. The individual works closely with the Chief Medical Officer (CMO) and the Chief Operations Officer (COO) on quality improvement measures through data collection and analysis, workflow assessment, development and implementation of enhanced protocols or procedures affecting the way TVHC clinical staff perform their respective job duties. The Director of Corporate Compliance and Quality serves as a channel of communication to receive and direct quality and compliance issues to appropriate resources for investigation and resolution. Also works as a final internal resource with which concerned parties may communicate after other formal channels and resources have been exhausted.

 

The individual in this role must command knowledge in FQHC standards of practice, as well as other legal and ethical codes and regulations applicable to FQHCs.

 

This is a full-time benefited position working 40 hours per week, typically Monday through Friday.


Benefits of working full time at TVHC:

  • Monday through Friday (8-5pm hours)
  • 100% employee only medical coverage (includes no co-pays). Spouse and dependent coverage also available. 
  • Dental, vision (spouse and dependent coverage available)
  • Generous PTO
  • 13 holidays
  • Flexible Spending Accounts
  • 403(b) retirement savings plan

Responsibilities

  • Manages day-to-day operations of the Compliance and Quality department including directly supervising Compliance and Quality Department staff.
  • Leads and supports ongoing development, refinement, implementation, measurement, ongoing quality improvement and effectiveness of TVHC’s Compliance and Quality Program Plan.
  • Documents and provides regular reporting to Executive Management and Board of Directors (BOD) on the status of compliance and quality programs.
  • Develops, implements, maintains, and revises policies and procedures for the general operation of the Compliance Program and its related activities to prevent illegal, unethical or improper conduct. Reviews other organizational policies.
  • Plans, coordinates, and provides guidance for the integrated functions of quality assessment and improvement, patient safety, and Patient Centered Medical Home accreditation. Utilizes quality improvement methodologies, supporting the development and implementation of clinical assessment/process improvement and redesign. Leads and participates on teams that identify the best known clinical and operational practices to achieve and retain optimal quality outcomes.
  • Provides technical information in an equitable and consistent manner for staff, management, and Board of Directors concerning practice regulations, laws and standards, along with other related matters; provides guidance, direction, and training, as applicable, or makes recommendations for effective correction of performance issues from a corporate compliance stand point.
  • Responds to alleged violations of rules, regulations, policies, procedures, and Standards of Conduct by evaluating or recommending the initiation of investigative procedures. Conduct investigative action and correction initiatives for all compliance issues. Follows through with all investigative procedures to resolution of the final outcome, developing and overseeing a system for uniform handling of such violations. Ensures proper reporting of violations or potential violations to duly authorized enforcement agencies as appropriate and/or required.
  • Institutes and maintains an effective compliance communication program for the organization, including promoting (a) use of the Compliance Hotline (EARS); (b) heightened awareness of Standards of Conduct and HIPAA rules, and (c) understanding of new and existing compliance issues and related policies and procedures.
  • Chairs the monthly Compliance and Quality Workgroup meetings and collaborates with management and staff to identify, review and support implementation of quality and compliance monitoring and audits as required by Health Resources and Services Agency (HRSA), Patient Centered Medical Home, Meaningful Use and health plan programs.
  • Works with the Human Resources Department and others as appropriate to develop an effective compliance training program, including appropriate introductory training for new employees as well as ongoing training for all employees and managers. May participate as consultant for employee disciplinary matters involving policy violations as needed.
  • Performs all duties in accordance with TVHC’s Service Excellence Standards.
  • Assumes other duties, including special projects, as assigned or needed.

Qualifications

  • Bachelor’s degree in public health, business management nursing, legal studies or related field, or equivalent, required. Master’s in, public health, business management, related field, or equivalent, highly preferred.
  • Minimum of three to five years’ experience working directly with corporate compliance and/or quality improvement programs in a healthcare setting in a lead or supervisory capacity.
  • Must have extensive knowledge and understanding of NCQA accreditation standards and relevant legislation, laws, regulations, precedents and protocol of clinical practice for FQHCs. Knowledge of comparative databases and reporting requirements, EHR systems strongly preferred.
  • Familiarity with operational, financial, clinical quality measurement and general personnel procedures and regulations required.
  • Certified Professional in Health Care Quality (CPHQ) or Certified in Healthcare Compliance (CHC) a significant plus. 

REQUIRED SKILLS

  • Capacity to work at fast pace with multiple priorities and deadlines.
  • Superior interpersonal skills. Able to work well with all levels of diverse work force.
  • Superior communication skills, both written and verbal.
  • Proven command of clinical operations standards, including a clear understanding of practice management, patient flow and internal systems for effective operations of a community health center.
  • Knowledge of chain of command as it relates to corporate compliance reporting, including appropriate protocols for notice and respective timelines.

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