Performance Improvement & Compliance Administrator
Our Performance Improvement and Compliance Administrator designs and implements programs, policies, and practices to help ensure that all departments are in compliance with The Joint Commision (TJC) accreditation standards, Health Insurance Information Portability and Accountability Act (HIPAA) regulations and all applicable state, federal and local statutes pertaining to hospital licensing and regulation. Works directly with the Hospital Administrator to ensure compliance with the contract between the hospital and Department of Children and Families (DCF) for the management of the hospital.
- Bachelor degree in human services or health care field.
- Master degree is preferred
- Five (5) or more years experience in a health care overseeing compliance and accreditation requirements. Hospital industry experience preferred.
- Knowledge of TJC or comparable agency accreditation requirements.
- Ability to effectively communicate verbally and in writing.
- Ability to read and interpret documents such as facility policies and procedures and procedural manuals. Ability to write moderately complex reports and correspondence. Ability to speak effectively before groups of customers or employees of organization.
- Ability to work with computers and the necessary software typically used by the department.
- None required
- Designs and implements programs, policies, and practices to insure that all departments are in compliance with The Joint Commission (TJC) accreditation standards, HIPAA regulations, and all applicable federal, state and local statutes pertaining to hospital licensing and regulation.
- Tracks laws and regulations that might affect the facility’s requirements.
- Works directly with the Hospital Administrator to ensure compliance with the contract between hospital and the state’s DCF for the management of the facility.
- Coordinates the preparation and submission of responses and corrective action plans. Follows-up with DCF representative, TJC, American Health Care Association (AHCA), Center for Medicare and Medicaid Services (CMS) or any other accreditation or regulatory body.
- Provides direct supervision to the Medical Records Coordinator.
- The above responsibilities are a highlight of responsibilities and not a full list. Other responsibilities may be performed as assigned.