JOB POSTING- Open until filled
JOB SUMMARY
This position provides leadership to the accreditation, quality and safety functions for the Sophie Trettevick Indian Health Center and will play a key role in the creation of the infrastructure required for achieve the highest quality of service delivery and accountability.
ESSENTIAL JOB DUTIES:
- Develop, monitor, and enhance continuous quality improvement and meet all required Federal and Washington State regulations.
- Assist all health programs to meet accreditation standards and develop a culture of continuous quality improvement.
- Manage all aspects of Accreditation process to include: survey preparation, clinical and administrative reviews, and survey application submission. Develop and monitor corrective action plans as required in conjunction with the Health Director.
- Demonstrate ability to interpret accreditation standards, identify organizational gaps, and implement processes to meet standards and/or close gaps.
- Lead accreditation management to include the development of detail work plans, setting deadlines, assigning responsibilities, and monitoring/summarizing project progress.
- Conduct program and environmental patient safety audits ensuring compliance with all health care services requirements and accreditation standards.
- Manage the investigative process of all patient complaints, including HIPAA. Act as the lead investigator from intake to conclusion. Maintains investigative files and database to ensure proper quality assurance.
- Work closely with Program Managers and supervisors to ensure all required documentation is obtained and up to date on designated electronic storage sites.
- Develop, in conjunction with program managers, quality improvement program policies, procedures and strategies to establish quality performance benchmarks and corrective action strategies and monitor the progress,
- Responsible to maintain the approved Infection Control Manual and Exposure Plan program and administers the Employee Health Program and monitors and reports compliance for standards that include but not limited to employee immunizations, employee exposure and employee safety training.
- Provide routine staff orientation on employee health, hazard communications, Infection Control Manual and Exposure Control Plan.
- Monitor and track mandatory required training. Review and track monthly reports and offer follow-up advice or policy changes as needed.
- Monitor and maintain employee licenses, certifications, and required trainings through an approved electronic tracking system.
- Conduct training and coaching to facilitate understanding of the quality safety and accreditation requirements within the department and with patients.
- Coordinate with Operations to ensure compliance with the safety, maintenance, repairs and upgrades of all areas within the Health facilities.
- Assume a lead role and work closely with Facilities Manager and COO/CEO during inclement weather, power outages or emergency situations.
- Collect and organize documentation throughout the department for ongoing program needs or develops documents, as needed, to meet needs.
- Gather and create healthcare planning documents, general data and statistical or other background studies for healthcare. Assist in providing research projects for the CMO and CEO.
- Develop demographic and other statistical profiles and databases and other planning related data as requested by the CEO.
- Perform other related duties as assigned.
Education Required
- Bachelor’s degree in risk management or healthcare administration or related field preferred or any combination of relevant education and experience.
Minimum Related Experience
- Two years of supervisory experience
- Four years of experience in health care, preferably in a tribal government or non-profit organization
Required Licenses/Certifications
- Valid and unrestricted Washington State Driver’s License
Knowledge and Abilities
Knowledge of:
- Specialized medical terminology and ICD-10 CM and CPT coding
- Financial laws and regulations standard to a Tribal Healthcare facility
- Healthcare accreditation process and requirements
- HIPAA regulations, which mandate that the incumbent shall maintain complete confidentiality of all administrative, medical and personal records, and all other pertinent information that comes to his/her attention or knowledge.
Able to:
- Maintain confidentiality and communicate with tact and discretion.
- Adhere to IHS policies and regulations
- Abide by the Privacy Act of 1974 which mandates incumbent shall maintain complete confidentiality of all administrative , medical and personnel records
- Organize, plan, coordinate, and carry-out assigned tasks with accuracy and attention to detail.
- Provide excellent customer service and problem solve effectively.
- Demonstrate leadership and team building.
- Continually learn and utilize a variety of information systems and software.
- Pass pre-employment drug screening and background check(s).
PHYSICAL REQUIREMENTS:
Manual and finger dexterity for the operation of personal computer, office machines and routine paperwork. Tolerance to be exposed to computer screen for prolonged periods. Stamina to sit, stand and/or walk for prolonged periods. Mobility to bend, stoop, and/ or climb stairs. Ability to lift objects weighing up to 25 lbs. occasionally. Operate a motor vehicle.
SPECIAL REQUIREMENTS
Immunization Requirements: Must be fully immunized against measles, and rubella and provide official documented proof of vaccination prior to employment. Employees are required to provide proof of other immunizations as recommended for healthcare workers by the Centers for Disease Control and Prevention, or of immunity to these diseases. All employees shall have tuberculin (TB) test upon employment and annually thereafter, or have a follow-up plan approved by employee health if there is a positive test
Special Consideration: if you are allergic to any component of the vaccine or have documented history of severe reaction to vaccine or are currently pregnant you may not have to be immunized, however, you are required to provide documentation/proof, in order to be considered for employment.