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Northeast Georgia Health System is rooted in a foundation of improving the health of our communities.

About the Role:

Job Summary

The Hospice Compliance Supervisor is accountable for management and the coordination of an integrated Quality Assessment program. This position is responsible for facilitation of the endeavors which aim to position Hospice of Northeast Georgia Medical Center for successful compliance with the standards/rules/regulations of accrediting body. Provides leadership through acting as the context expert in hospice federal and state conditions of participation and accreditation standards. Through relationships with staff, administrators, physicians, and patients/families; will serve as the resource in the area of compliance, regulations, policies and procedures, and accreditation. Coordinates all QAPI activities and will lead appropriate projects and meetings. Assist with departmental writing of policies, procedures, and standard work, as requested.

Minimum Job Qualifications

• Licensure or other certifications:

• Educational Requirements: Associates Degree.

• Minimum Experience: Three (3) to five (5) years experience in healthcare accreditation, compliance, and quality assessment; preferably in hospice.

• Other:

Preferred Job Qualifications

• Preferred Licensure or other certifications:

• Preferred Educational Requirements:

• Preferred Experience:

• Other:

Job Specific and Unique Knowledge, Skills and Abilities

• Excellent oral and written communication skills; excellent customer service skills; positive interpersonal skills

• Understanding of performance improvement concepts and processes

• Ability to analyze data and correlate with financial and regulatory requirements and accreditation standards. Propose processes for ensuring compliance with same

• Well organized and detail oriented with a track record of follow through, completeness, and accuracy

• Ability to exercise sound judgment and maintain strict confidentiality of protected health information

• Ability to assess, plan, implement, execute, evaluate, and redirect for continuous process/outcome improvements

• Excellent attention to detail, time management and organization

• Accelerated computer skills - to include Excel, PowerPoint, Word, and report creation

• Ability to prioritize duties and projects with a willingness to work flexible hours to meet the needs of the department
  

Essential Tasks and Responsibilities

• Supervises the maintenance of medical records assuring accuracy, completeness and compliance with licensing regulations, accreditation standards and legal and ethical standards.

• Reviews all patient/family variances and complaints and take appropriate action. Processes variances and complaints per organizational policy. Immediately apprises the Hospice Executive Director of any Risk Management issues.

• Coordinates/facilitates problem solving/performance improvement activities for quality/regulatory issues and concerns.

• Assists as needed with screening, selection and recommendation of clinical supervisory staff for employment.

• Participates in orientation of new personnel to agency programs, policies and procedures.

• Responsible for completing payroll activities for direct reports and others as assigned.

• Responsible for overall management and maintenance of medical records and supervision of medical records staff.

• Coordinates the implementation of the patient/family satisfaction survey in accordance with agency policy and procedure of organization. Coordinates findings with National Hospice and Palliative Care Organization for benchmarking.

• Coordinates all performance improvement and compliance activities.

• Provides formal and informal education and updates staff concerning regulatory and accreditation standards and requirements.

• Provides timely information to Hospice Executive Director about status of compliance with regulatory and accreditation standards, as appropriate.

• Coordinates the logistics of the actual regulatory/accreditation visits/survey activities, as appropriate.

• Utilizes established outcome criteria, industry standards and all guidelines to recommend action plans to the Hospice Leadership Team to promote improvements and to ensure compliance in all areas.

• Coordinates/facilitates problem solving activities with the Hospice Administrative Team, as requested.

• Prepares Hospice Annual Program Evaluation

• Evaluates physician and referral source satisfaction with services and works to meet expectations. Facilitates resolution of difficult issues with physicians and referral sources.

• Provides timely reports requested by Executive Director.

• Facilitates departmental problem-solving/improvement activities related to quality improvement, accreditation standards, or state and federal regulatory concerns.

• Represents the department and contributes expertise to committees or project teams as appropriate and assigned by Executive Director.

• Maintains general knowledge of the hospice regulatory standards.

• Participates in performance improvement activities by contributing suggestions, experience and expertise to promote efficiency and excellent outcomes.

• Develops, reviews and updates standard work, department policies and procedures pertaining to individual duties and responsibilities to ensure department compliance with all state, regulatory and hospital requirements.

• Maintains commitment to professional growth by keeping current on new trends and advances in regulatory trends.

• Oversees compliance with accrediting body, CMS, and state rules and regulation requirements.

• Responds to staff inquiries regarding regulatory standards for reference purposes.

• Participates in the establishment of methods to communicate regulatory information to Hospice staff.

• Completes required updates to the accreditation application to meet requirements.

• Competent in performing quality audits.

• Performs other duties, as assigned.
  

Physical Demands

• Weight Lifted: Up to 30 lbs, Occasionally 0-30% of time

• Weight Carried: Up to 30 lbs, Occasionally 0-30% of time

• Vision: Heavy, Constantly 66-100% of time

• Kneeling/Stooping/Bending: Occasionally 0-30%

• Standing/Walking: Occasionally 0-30%

• Pushing/Pulling: Occasionally 0-30%

• Intensity of Work: Frequently 31-65%

• Job Requires: Reading, Writing, Reasoning, Talking, Keyboarding, Driving

Working at NGHS means being part of something special: a team invested in you as a person, an employee, and in helping you reach your goals.

NGHS: Opportunities start here.

Northeast Georgia Health System is an Equal Opportunity Employer and will not tolerate discrimination in employment on the basis of race, color, age, sex, sexual orientation, gender identity or expression, religion, disability, ethnicity, national origin, marital status, protected veteran status, genetic information, or any other legally protected classification or status.