Develops and implements the organization's risk management
program in a manner that fulfills the mission and strategic goals
of the health center while complying with State and Federal laws
and regulations and accreditation standards related to quality,
safety, and risk management. Develops and implements compliance
department activities related to customer satisfaction, performance
improvement, and risk reduction. Implements and manages health
center emergency response activities and program deliverables.
Ability to collect, review, and interpret data required for
reporting. Reports statistical data using Microsoft excel
(including graphs). Requires excellent communication skills and
critical thinking; able to make recommendations to assist in staff,
patient and visitor complaint resolution.
Essential Duties and Responsibilities:
Participate in the health center's performance improvement,
safety, infection prevention, compliance and emergency response
Monitors and collects data related to performance improvement
Performs data entry into personal computer using appropriate
software and programs.
Provides weekly and/or monthly statistical reports/graphs on as
Maintain required department records, reports, documents and
files necessary to ensure proper documentation and follow up on
responsibilities, department operations and assignments.
Conduct Compliance department training for new hires and
annually for all staff, students & volunteers; to include but not
limited to topics on OSHA, complaint process, incident/accident
reporting, health center policies, HIPAA, age-specific care,
incident command system, compliance program, infection prevention,
patient rights & responsibilities, use & handling of personal
protective equipment and emergency equipment & supplies.
Responsible for training on use, distribution of and inventory
maintenance of emergency equipment (disaster kits, communication
equipment, PPE, and other supplies).
Review / revision of MSDS and chemical inventory lists. Monitors
and ensures department compliance with maintaining documents on
site and proper use of chemicals. Maintains current MSDS files at
Implementation and coordination of patient satisfaction survey
(written, phone interview, and on-site) and provides written report
Implementation and ongoing coordination of patient focus group
for patient satisfaction and improvement activities.
Monitors patient / visitor complaints and suggestions (comment
lock boxes) and make recommendations to reduce agency exposure to
risks and improve services.
Checks lock boxes and compliance hotline and responds promptly
per health center policy.
Assists with implementation and monitoring for adherence to new
and revised agency policies.
Assist with policy writing, electronic access (shared drive) and
formatting for print.
Monitors equipment checks assessing compliance with service
maintenance and safety checks.
Performs frequent monitoring of the environment of care and
conduct annual hazard vulnerability analysis for each site,
reporting findings to Performance Improvement committee.
Monitors and reports compliance findings related to Joint
Monitors and reports compliance findings related to Patient
Centered Medical Home and NCQA requirements.
Function within the legal and ethical parameters of your
profession, as a member of the interdisciplinary healthcare team
and according to the policies and procedures of Betty Jean Kerr
People's Health centers.
Requires Bachelor Degree or equivalent experience.
Experience in public health environment a plus and excellent