Director of Quality Services-Nexus Neurorecovery Center-Conroe, TX


Under the general supervision of the CEO, the Director of Quality Services is given the necessary authority and responsibility to perform the duties of the Director of Quality Services. Acts as the Compliance and Privacy Liaison for the facility works in tandem with Directors of all departments to ensure facility-wide compliance in all area.
 Directs facility-wide Performance Improvement activities.
 Ensures monitoring, aggregation of data and evaluation of mandatory monitoring completion.
 Educates staff and physicians regarding the Performance Improvement program, processes, teams and findings.
 Works in partnership with the PI physician or medical director to monitor physician performance improvement initiatives, competence and peer review.
 Facilitates PI teams to improve facility processes, patient outcomes and/or patient/facility safety.
 Serves as a resource regarding performance improvement, accrediting and regulatory and compliance issues.
 Ensures investigation (intensive as indicated) of all incidents/occurrences/near misses/sentinel events occurs as indicated with action steps implemented as defined.
 Coordinates PI Committee meetings at least quarterly.
 Aggregates and presents Performance Improvement data with proposed action plans, recommendations for improvement to appropriate leaders/groups.
 Coordinates continual facility-wide compliance with CARF standards.
 Assists leaders in department indicators and compliance activities.
 Audits medical records to ensure compliance on designated criteria.
 Prepares presentation reports with action plans and evaluations.
 Ensures ongoing review of facility practices in order to maintain facility licensure and accreditation.
 Reviews Occurrence Reports; monitors and tracks for potential trends or other possible problems/concerns.
 Provides occurrence report/statistical analysis to the Executive Committee and Governing Board.
 Ensures compliance with all regulatory agencies governing healthcare delivery and the rules of the accrediting bodies.
 Participates in facility/medical staff committee meetings as assigned.
 Attends and serves on professional/community organizations as a facility representative.
 Works with facility Safety Officer in implementing and maintaining programs for patient/employee safety.
 Assists in ensuring staff remains in compliance with facility and department policies and procedures.
 Contributes to staff meetings ensuring appropriate information is reported and communicated.
 Coordinates and participates in development/maintenance and implementation of fire, hazardous materials, disaster, utilities, security, medical equipment, evacuation plans.
 Reviews and promptly acts on reports and recommendations from regulatory and inspecting agencies.
 When appropriate, communicates operational concerns and needs to CEO.
 Serves as facility representative in its relationships with outside agencies and vendors.
 Serves as facility HIPAA Privacy Officer.
 Ensures that Policies and Procedures reflect HIPAA requirements and that staff attend the required annual in-services.
 If applicable, maintains Provider Unit in adherence with all state and federal laws and regulations.
 Ensures all policies and procedures are current.
 Consults with appropriate department heads in order to review and initiate organization-wide policies and procedures needed to accomplish facility goals, objectives and programs.
 Serves as facility Compliance Liaison.
 Consistently completes all required paper work in a timely manner.
 Performs other duties as assigned.

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Job Requirements


 Experience in Performance Improvement/HIPAA/Risk Management.
 Prefer experience in management with regards to supervising, managing, and working with a variety of people on an individual and group basis.
 Extensive experience in compliance and conducting internal investigations.
 Background in healthcare.
 Experience with TNA/ANCC Continuing Education Provider status preferred.

Education Required

 Prefer B.S. in nursing or equivalent clinical or quality background.
 Continuing education in the area of nursing practice, Patient safety and quality.
 Extensive knowledge in CARF standards and Medicare/Medicaid regulations.

Additional Information

 Certified in AHA BLS/CPR
 Must obtain current tuberculosis test within the first fourteen (14) days of employment and annually after that.
 Maintain current certification in good standing during employment with this facility, or obtain within thirty (30) days of hire