Recovery Centers of America at King of Prussia
Position Overview: Under the supervision of the Corporate Director of Quality Management and Compliance, the Outpatient Services Compliance Manager is responsible for the implementation, management, coordination and oversight of RCA’s Quality Assurance and Compliance activities at all Outpatient facilities throughout the RCA organization.
Daily Responsibilities Include:
- Incident Reports
- Assist the site leadership in the management of Incident Reports
- Prepare to discuss/identify trends in daily meeting
- Ensuring all are investigated with interviews and collecting data
- Ensure all are closed
- Follow up with team to make sure incident follow up is completed
- Follow up with KOP team for any state reporting requirements
- Assist the site leadership in the management of Incident Reports
- IR re-training/re-education as needed
- Conduct investigation (interviews, review of footage, root cause as needed)
- Work with site leadership to ensure sure appropriate follow ups and responses to all patient (or staff) grievances are received in appropriate time frames.
- Work with site leadership to investigate grievance as needed.
- Patient Satisfaction Surveys
- Assist in the development, implementation, rollout and ongoing monitoring of patient satisfaction surveys at all Outpatient, MAT, and Laboratory sites.
- Assist site leadership with identifying trends in survey results and developing pips as needed.
- Quarterly Environment of Care and Compliance walkthroughs at all Outpatient, MAT and laboratory locations
- Assist in development and monitoring of PIPs as needed based on findings from walkthroughs
- Policy & Procedure and Protocol Governance for Outpatient, MAT and Laboratory sites
- Ensure protocol development has been reviewed/approved by governing committee
- Ensure policies and protocols meet regulatory requirements, including but not limited to The Joint Commission (TJC), Commission on Accreditation of Rehabilitation Facilities (CARF) and College of American Pathologist (CAP).
- Ensures dissemination and understanding of approved P&Ps
- Update P&P manual on site
Plan of Corrections (DCOs, CAPS, PIPS)
- Assist facility leadership at all Outpatient, Laboratory and MAT sites in development of any and all plans of correction whether they are generated from an external monitoring agency or from internal monitoring conducted by the Compliance Team.
- Monitor completion of all Plans of Correction to ensure they are completed and submitted on or before due date outline.
- Ensure appropriate follow up and any measurements of success indicated on the plans are conducted and reviewed by leadership for ongoing compliance monitoring.
- Regulatory and Accreditation Awareness/readiness related to Outpatient, MAT and Laboratory regulations. Including but not limited to The Joint Commission (TJC), Commission on Accreditation of Rehabilitation Facilities (CARF), College of American Pathologist (CAP).
- Training on regulatory and accrediting requirements
- Ensure site and corporate leadership team is kept apprised on changes to regulatory requirements that may require policy or process changes.
- Survey and Survey Prep
- Assist in state, local, accrediting body preparation
- Serve as site liaison during on site survey
- Participation in site QAPI and Safety Committee Meetings
- Ensure appropriate agenda’s and meeting minutes are collected.
Overall Strategic Responsibilities:
- Strategic oversight encompasses all Outpatient, Laboratory and MAT operational areas that include but not limited to: risk management, regulatory/payor/accreditation compliance, outcomes management, and quality management:
- Implementation and monitoring of performance improvement plans and strategies
- Proactive analysis of systems and processes that underscore adverse/high-risk events and/or decline in measurement scores and implement action steps to address
- Proactive project management for implementation of quality initiatives
- Ongoing survey readiness and education of all levels of staff in regulatory, accreditation, and organizational expectations
Education and Experience:
- Bachelor’s degree in a related field (healthcare management, psychology, social services, nursing); master’s preferred
- Five years of clinical experience and two years quality management experience with a focus on Laboratory Compliance or Medication Assisted Treatment Compliance.
- Understanding of systems of quality measurement/management and evidence-based practices (American Society of Addiction Medicine, Substance Abuse and Mental Health Services Administration, Healthcare Effectiveness Data Information Set, National Committee for Quality Assurance, National Institute on Drug Abuse, National Alliance on Mental Illness)
- Understanding of Risk Management best practices as governed by the American Hospital Association, American Society for healthcare risk management
- Previous experience implementing systems and process to include organizational change management
- Understanding of managed care to include commercial insurance and CMS governance (Medicaid/Medicare)
- Experience and knowledge of ongoing survey readiness and survey processes to include federal regulations, state regulations, The Joint Commission (TJC), Commission on Accreditation of Rehabilitation Facilities (CARF), and College of American Pathologist (CAP) surveys and standards.
- Experience working with and developing solutions within electronic health records
- Proficiency in Microsoft Office products (Office, Excel, Project)
- Excellent organizational skills required
Customer Service: Demonstrates concern for meeting internal and external customers’ needs in a manger that provides satisfaction for the customer within the resources that can be made available.
Impact and Influence: Works effectively with and through others including those whom there is no formal authority over.
Project Management: Coordinates the diverse components of the project by balancing scope, time, cost, and quality.
Communication: Communicates well both verbally and in writing, creates accurate and punctual reports, delivers presentations, shares information and ideas with others, has good listening skills.
Work Environment: This job operates in a professional office environment. This role routinely uses standard office equipment such as computers, phones, photocopiers, and filing cabinets. The noise level in the work environment is usually moderate.
Physical Demands: The employee is occasionally required to stand; walk; sit; reach with hands and arms; climb or balance; and stoop or kneel. Specific vision abilities required by this position include close vision, distance vision, color vision, peripheral vision and the ability to adjust focus.
Travel: Up to 50% travel is required which includes local, out-of-the-area, and overnight travel.