Performance Improvement & Compliance Administrator
Our Performance Improvement and Compliance Administrator directs hospital-wide performance improvement activities. Designs and implements programs, policies and practices to ensure that all departments are in compliance with DHEC, NCCHC, and TJC accreditation standards, HIPAA regulations and all applicable state, federal and local statutes pertaining to hospital licensing and regulation, as applicable. Works directly with facility leadership to ensure compliance with the contract between the hospital and contracting agencies for the management of the hospital. In addition, this position ensures compliance to all organizational, contractual, state and federal rules and regulations.
- Bachelor degree in human services or health care field.
- Master degree is preferred
- Five (5) years management demonstrated experience in compliance or performance improvement administration
- Previous experience in a hospital or corrections environment preferred (A combination of educational and work experience may be taken into consideration based on management's discretion.)
- Knowledge of TJC or comparable agency accreditation requirements
- 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 facilities requirements.
- Works directly with the leadership 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 (as applicable) 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.