Medical Compliance/QI Specialist
Full Time
Winter Haven, FL 33880
Posted
Job description
Title; Medical Compliance and Quality Improvement Specialist
Reports to: Quality Compliance Supervisor/Safety Officer
FLSA Status: Non-Exempt
Personnel Supervised: None
POSITION SUMMARY:
The Medical Compliance and Quality Improvement Specialist works in coordination and cohesively with the Chief Quality Officer/Risk Manager (CQO/RM) and the Quality Compliance Supervisor/Safety Officer. The focus of this position will be to ensure medical program compliance, quality improvement initiatives, complete Environment of Care rounds, educate staff and work with all levels of leadership to improve the clinical and front desk operations of Central Florida Health Care (CFHC).
The Medical Compliance and Quality Improvement Specialist will assist in establishing, assuring, and assessing clinical and operational compliance while implementing process improvement initiatives across CFHC. This position is responsible for the goals and objectives of CFHC’s Quality Improvement Plan. This employee will also work with clinical staff and leadership on compliance and re-training related to the Joint Commission’s Standards, HRSA, OSHA and all other local, State and Federal Guidelines pertaining to medical compliance and quality improvement.
MINIMAL QUALIFICATIONS:
- Graduate of an accredited Medical Assistant Program and/or graduate of a related Associates Degree program
- Certification/Registration - Medical Assistants must be certified or registered and certified and registered Medical Assistants must maintain certification
- Current CPR
EXPERIENCE:
Required:
- Minimum of 2 years of experience in the medical field
- Minimum of 2 years clinical experience
- Experience with Microsoft Word, Excel, and PowerPoint
- Experience with electronic health records
Preferred
- Knowledge of Joint Commission, and/or quality management
- Knowledge of CDC guidelines
- Knowledge of OSHA and HRSA standards for healthcare
- Ability to work under tight deadlines and remain flexible
- Exceptional team, communication, and written/oral skills
RESPONSIBILTIES AND PERFORMANCE EXPECTATIONS include, but are not limited to, the following:
- Ensure Clinical and Operational Compliance and Quality Improvement initiatives at all medical locations
- Educate staff on meeting requirements as it relates to The Joint Commission, OSHA, AHCA, Florida Board of Medicine/Nursing, HRSA, CDC and Manufacturers Guidelines and all other local, state, and federal entities
- Complete monthly Environment of Care (EOC) rounds at each clinical and administrative locations, parking lot, front desk operations, lobbies, clinical exam rooms, nurses’ stations, laboratories, biohazardous waste storage area, emergency management routes/equipment/lighting and warehouses
- Observe medical front desk and clinical staff during administrative and clinical operations to ensure proper procedures are being followed, including customer service techniques and patient identification requirements. Perform training and implementation of process improvement techniques as necessary
- Observe medical staff during patient discharge to ensure proper procedures, forms and instructions are followed and given to patients. Perform training, and implementation of process improvement techniques as necessary.
- Complete and submit monthly EOC reports within 24hrs of inspection
- Will work with Supervisor’s and staff during EOC rounds to immediately correct non-compliance. If site and/or staff non-compliance continues without resolution the issues will be shared with the supervisor and Human Resources.
- Research process improvement initiatives and implement continuous improvement protocols
- Track and trend data relating to operational, clinical and laboratory compliance and quality improvement projects
- Track PDSA projects for all CFHC departments
- Re-Train medical front desk, laboratory and clinical staff on compliance issues and manufacturer guidelines as necessary
- Inspect and ensure manufacturer’s guideline manuals for laboratory and clinical staff are available, correct and organized
- Responsible for quality improvement program audits, and education as it relates to Peer Review and CFHC UDS measures
- Work with facilities staff regarding quality improvement projects related to building operations
- Organize, schedule, send out, tally and review organization peer review monthly, quarterly, and annually
- Work with Human Resources, Chief Medical Officer and Clinical Staff Coordinator to ensure peer review is completed on time and compliant with FTCA, HRSA and Joint Commission credentialing and privileging requirements
- Work with community health center partners to coordinate peer review for CFHC providers and the external providers as needed
- Track, trend, and report peer review data monthly
- Ensure PCMH program compliance including but not limited to Huddles, signage, and pamphlets
- Track HRSA quality UDS measures via dashboards monthly, quarterly, and annually which are needed to complete peer review and to earn Quality Badge awards from HRSA and implement process improvement projects to increase UDS measures percentages as necessary
- Work with Supervisor and CQO/RM to generate annual year over year UDS measure report, baselines, and goals
- Research and keep up with HRSA quality award badge requirements and implement process improvement project needed to meet badge requirements
- Keep up with Athena Clinical Buckets as it relates to clinical, administrative and laboratory compliance and quality improvement
- Other duties as assigned
PHYSICAL REQUIREMENTS:
- Able to work flexible hours
- Standing/walking/sitting for long periods
- Independently mobile
- Ability to lift, up to 50lbs
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