Primary Function:
The Quality & Compliance Specialist is responsible for the monitoring, data collection, evaluation, analysis, and assurance of compliance processes for Hospice of Davidson County (HODC) and required public reporting mandated by Centers of Medicare and Medicaid. This position collects data from identified monitoring initiatives, analyzes, and produces reports monthly, quarterly, and annually. This position is the assigned Privacy Officer. The Privacy Officer assists the Chief Executive Officer and Director of Quality & Compliance in providing compliance with HODC policies and procedures related to the protection of health information and Federal and State regulations related to patient privacy.
Supervision: Director of Quality & Compliance
Qualifications:
1. A Bachelor’s degree (preferably in a business, marketing, communications, public relations, or human services field) with experience in monitoring processes, data management, analysis, and reporting. This position requires the ability to use Excel, Word, and/or Access.
2. Experience and understanding of Medicare federal and state regulations, state licensure, and accreditation requirements.
3. Maintain current unrestricted North Carolina driver’s license and maintain minimum
automobile liability insurance for the duration of employment.
Knowledge and Skills:
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1. Accomplishes day-to-day work operations by initiating, coordinating, and applying data entry policies and procedures and data submission protocols.
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2. Improve data entry quality results by completing audits, identifying trends, determining system improvements, evaluating and implementing changes to enhance required data submission processes.
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3. Ability to communicate effectively to the Board of Directors, staff, patients, families, and to other groups about data trends.
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4. Regular, reliable attendance is essential.
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5. Must be current in federal and state requirements of Hospice.
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6. Ability to work interdependently.
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7. Willingness to maintain and increase professional skills and knowledge.
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8. Ability to work with the team concept of patient/family care and to react in crisis situations independently.
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9. Knowledge of community resources.
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10Ability to work with community agencies and ancillary health services.
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11Ability to communicate clearly in writing and speaking.
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12Ability to collect, analyze, and evaluate data and develop reports
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13Commitment to the Hospice concept and standards.
Job Duties:
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1. Participates with Leadership Team to ensure that Hospice of Davidson County maintains a
- high level of quality and accuracy in data collection, analysis reports, and public reporting
- submissions.
- 2. Manages data submission to CMS, external vendors with CAHPS, Hospice Item Set, and
- scanning processes for archived records.
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3. Works with the Director of Quality & Compliance with our benchmarking efforts.
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4. Handles the department’s quarterly monitoring efforts to ensure compliance with all required
- documentation per state and federal regulations and scheduled monitoring efforts.
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5. Acts as a patient/family advocate at all times. Handles, documents, and tracks patient complaints effectively and efficiently. Tracks and completes data entry of all adverse events to external vendor system within the outlined timeframes.
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6. Coordinates and schedules the face-to-face visit schedules for the Medical Director and Nurse
- Practitioner. Monitors timeframes of required face-to-face visits to ensure compliance.
- 7. Performs monthly chart audits with percentage based on census. Provides data analysis on
- chart audit results.
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8. Compiles data for selected performance measures and survey results to be reported to Data
- Vendor and at QAPI, Professional Advisory Committee, and at Board of Director meetings.
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9. Maintains a safe and clean work area to promote work place safety.
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10. Maintains confidentiality of Protected Health Information (PHI) at all times.
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11. Performs other duties or special projects as requested by the Chief Executive Officer and/or
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The Director of Quality & Compliance.
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12. Participates in hospice sponsored in-service training. Handles set up for webinars or
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web based trainings, documentation of attendees, and CEU paperwork.
- 13. Participates in QAPI program.
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14. Participates on Hospice committees as needed.
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15. Performs job duties in accordance with all Hospice policies, procedures, professional
- and community standards.
- 16. Performs all other duties assigned by Director of Quality & Compliance
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17. Abides by the Hospice Professional Code of Conduct.
Privacy Officer Job Duties:
- 1. Assists in the interpretation of State laws and Federal regulations, including the HIPAA
- Privacy Rule.
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2. Handles all breaches and reports to the appropriate authority per regulations.
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3. Develop and implement comprehensive privacy policies and procedures.
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4. Serves as the designated contact person in Hospice of Davidson County Notice of Privacy
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Practices and receives questions and complaints related to the protection of health
- information, patient privacy, and violations of Hospice of Davidson County’s privacy
- practices.
- 5. Monitors systems and processes for appropriate access to, use and disclosure of, and
- requests for protected health information annually.
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6. Provides leadership in complying with regulations related to patient privacy and protected
- health information.
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7. Ensures that the Notice of Privacy Practices, authorization forms and privacy policies and
- procedures conform to the requirements of the Privacy Rule.
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8. Ensures that daily operations and actual privacy practice conform to requirements as outlined
- in policy and procedures.
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9. Ensures that all documentation required by the Privacy Rule is maintained and retained for
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six years from the date it was created or was last in effect, whichever is later.
Physical Demands:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions.
While performing the duties of this job, the employee is regularly required to stand, walk, sit, use hand to finger, handle or feel objects, tools or controls; and reach with hands and arms, to talk or hear.
The employee is occasionally required to stand, walk, climb, or balance; stoop, kneel, crouch, or crawl and smell. The employee must occasionally lift and/or move up to 50 pounds. Specific vision abilities required by this job include close, distance, color, peripheral and depth perception and the ability to adjust focus. The noise level in the work environment is usually moderate.
