Director Of Compliance/Quality Management Full Time

Vibra Healthcare Inc. Mishawaka , IN 46544

Posted 3 months ago

Organization Vibra + Ernest

Rehabilitation Hospital of Northern Indiana is a free-standing new construction inpatient rehab hospital located at 4807 Edison Lakes Parkway in Mishawaka, Indiana. This building is currently under construction and will be finalized in the spring of 2020. This beautiful facility is a 55,210 square foot two-story building that will have 40 private rooms, a large therapy gym with high tech equipment and an outside ambulatory courtyard, on-site dialysis, pharmacy and radiology. At our facility, we will treat a wide variety of patients such as those recovering from a Stroke, Brain Injury, Spinal Cord Injury, Multiple Trauma, Amputation, Neurological conditions, orthopedics and medically complex patients.

Rehabilitation Hospital of Northern Indiana in Mishawaka, Indiana - a NEW start up hospital - is seeking an experienced Director of Compliance/Quality Management to join and lead our newest location by February 2020!

The Director of Compliance/Quality Management provides clinical leadership for the following areas: Infection Prevention/Control, Medical Staff Services, Regulatory Compliance, Risk Management, and Quality Management/Improvement. Integrates the hospital's mission and "Guiding Principles" into daily practice.

Essential Functions:

  • Oversight of and implementation of the Infection Prevention & Control Program. Demonstrates and maintains knowledge of infection prevention and control processes utilizing CDC as the basis of this knowledge. Completes an annual risk assessment, annual evaluation of program effectiveness, plan update, and develops quality measures as indicated.

  • Collaborates with the medical staff regarding functions related to medical staff privileging and credentialing, performance improvement measurements, professional practice evaluation development and reviews, and aggregation by practitioners. Reports the results to the medical staff leadership.

  • Facilitates the hospital performance improvement program through the collaboration with other hospital leaders. Provides guidance regarding measurements, data collection, analysis, conclusions, and process improvement. Ensures that the teams and committees meet as required by Federal, State, and local requirements, as well as within the needs of hospital operations and inclusive of performance improvement teams, FMEA teams, other teams, and committee meetings.

  • Implements and manages risk management functions including incident reporting, investigational follow up, grievances, root cause analysis, provides notices of potential claims, and litigation management in conjunction with senior leadership. Reviews legal medical record requests and provides recommendations regarding the potential of litigation risk to management.

  • Ensures submission of data to internal and external databases, as required by accreditation and regulatory agencies, is submitted timely and accurately. Communicates with external referral agencies regarding community acquired infections and reports required infections to health departments.

  • Educates Medical Staff and hospital employees during initial orientation, re-orientation, and as education in area of expertise as indicated.

  • Facilitates compliance for the facility for related to CMS, The Joint Commission, and State/Federal regulations. Completes audits to identify ongoing compliance.

Qualifications/Skills:

  • Registered Nurse OR a combination of a Bachelor's Degree in a biological science and APIC (Association for Professionals in Infection Control and Epidemiology) Certification required

  • Minimum four years clinical experience preferred

  • Two years in clinical compliance role preferred

Additional Qualifications/

Skills:
  • Knowledge of and resource for Federal, State and the Joint Commission standards and hospital specific rules and regulations.

  • Knowledge of clinical operations and procedures.

  • Ability to maintain quality, safety, and/or infection control standards.

  • Demonstrates general computer skills including: data entry, word processing, email, and record management.

  • Demonstrates critical thinking skills: Using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions or approaches to problems.

  • Effective organizational and time management skills.

  • Effective written and verbal communication skills.

  • Ability to maintain proper levels of confidentiality.

  • Ability to work closely and professionally with others.

Our recruitment team wants to get to know you. Share your passion! Please complete our online application and submit your resume for immediate consideration.

If selected, our interview process includes phone interviews, in person interviews, and several vetting tools.

Thank you for taking the time to consider a career opportunity with our hospital.


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Director Of Compliance/Quality Management Full Time

Vibra Healthcare Inc.