Associate Director- Quality and Compliance

Program:	Fallon Tribal Health Center	Grade:	GS-19
Supervisor:	Health Director	Range:	$29.31-$35.00
Position Type:	Regular Full-time
FLSA Status:	Exempt     Non-Exempt     Public Safety

POSITION DESCRIPTION

The Associate Director – Quality and Compliance is under the general supervision of the Health Director.  The incumbent is responsible for assisting in the development, implementation, evaluation and supervision of assigned components of the Health Center’s quality improvement programs, clinical case management, regulatory affairs and accreditation.  Responsibilities include developing and implementing policies and operationally practices and coordinating and promoting common activities of assigned components to ensure the delivery of quality and fiscally responsible health care.  This position is also responsible for developing operational and policy and procedures to integrate services, eliminate duplication and optimize safety.  Does related work as required.

ESSENTIAL DUTIES & RESPONSIBILITIES

1. Research, develop and administer a plan to ensure that the Fallon Tribal Health Center obtains and maintains full accreditation with the Accreditation Association for Ambulatory Health Care (AAAHC).
2. Assessment of healthcare compliance policies and procedures; assist in updating or developing new procedures; assist in updating or developing new policies to enhance operations or/and internal controls or to consider new areas.
3. Monitors and administers compliance with federal, state, and local regulations.
4. Investigation of potential violations and taking appropriate actions to correct them.
5. Complete risk analysis on healthcare compliance, discover areas of potential compliance risk and vulnerability, and create and implement solutions to eliminate the potential risks.
6. Must follow all safety procedures and policies in carrying out duties and responsibilities, and must support a culture of great customer service and high quality in the organization.
7. Responsible for implementing healthcare audits, such as the establishment of objectives, goals, quality measures, and timelines for the team’s activities in a timely manner.
8. Responsible for conducting reviews of compliance work following established compliance plans, appropriate standards, metrics and prescribed program and departmental policies.
9. Manage and direct healthcare training and educational programs.

KNOWLEDGE, SKILLS & ABILITIES

1. Experience and ability to initiate, develop, maintain, and review policies and procedures for the operation of a healthcare compliance program and other similar activities to prevent unethical, illegal, or improper conduct.
2. Healthcare compliance evaluation and audit experience to be able to discover operational problems and recommend and execute strategies to provide needed solutions.
3. Strong ability to prioritize and perform multiple projects concurrently.
4. Strong communication skills to effectively report project risks and progress to senior management and colleagues.
5. Strong knowledge of Windows, Word, Excel, PowerPoint, and Outlook and other software applications as needed.
6. Proven ability to collaborate and advise management on compliance matters; ability to develop practical business solutions and to facilitate risk assessment.
7. Knowledge of labor laws concerning health, safety, and management initiatives to ensure that all employees are protected at all times.

QUALIFICATION REQUIREMENTS

(To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions)

1. Bachelor’s degree required in healthcare administration or related field; Master’s desired.
2. Three to five years of experience with healthcare compliance in administration or clinical area.
3. Three years recent experience in an acute care outpatient community healthcare setting and in a leadership role pertaining to federal and state healthcare regulations and other healthcare regulatory compliance matters.
4. Three years of training and experience in management, program development, project coordination and/or equivalent.
5. Current Registered Nurse license, or license appropriate for the incumbent’s related healthcare field.
6. Strong understanding of AAAHC
7. Advanced education in healthcare, safety, and/or compliance field.
8. One to three years supervisory experience.

EMPLOYMENT INFORMATION

Fallon Paiute-Shoshone Tribe and Native American/Indian Preference:  Employment preferences to members of the Fallon Paiute-Shoshone and to members of federally-recognized Indian Tribes shall apply to this position pursuant to the Tribe’s Personnel Policies.  Persons of Tribe and/or Indian ancestry and wish to claim these employment preferences should submit a copy of the Tribal Enrollment Card/Certification indicating the name of the Tribe they are enrolled with.

U.S. Veteran’s Preference:  Preference to opportunities to veterans honorably discharged from the United States Armed Forces shall apply to this position pursuant to the Tribe’s Personnel Policies.

Equal Opportunity Employer:  The Fallon Paiute-Shoshone Tribe does not discriminate on the basis of race, color, national original, sex, religious preference, age, handicap, marital status, political preference, genetics or membership or non-membership in any employee organization, except as allowed by Federal and/or Tribal Law.

Drug Free Workplace:  The Fallon Paiute-Shoshone Tribe is a drug-free workplace.  All employees are subject to a pre-employment and random drug screens.