Director Compliance and Medical Staff Affairs

Executes and integrates quality, safety, compliance, and internal audit plans across Lincoln Memorial Hospital. Leads, plans, directs, and coordinates all of the medical staff, compliance, and risk management resources within LMH, including operations improvement, peer review, privacy, patient safety, quality, accreditation, and emergency preparedness. Interfaces regularly with the MH leaders and department to ensure alignment of health system priorities, strategies, and operations. Leads development of respective dashboards, scorecards, and decision support tools to ensure engagement and improvement of key performance indicators.

Provides administrative leadership to Compliance, Medical Staff Affairs, Patient Access, Patient Resources and Health Information Management. Leadership is performed in accordance with hospital rules and regulations, Joint Commission guidelines, Medicare and Medicaid regulations, and federal and state statutes. Serves as the Risk Manager and Compliance and Privacy Liaison with direct reporting to the LMH Board of Directors.

Embodies the Memorial Health values of Safety, Integrity, Quality, and Stewardship that support our mission and vision.

Education:

• Bachelor’s degree required. Master’s in business, healthcare administration or related field preferred.

Licensure/Certification/Registry:

• Certifications in patient safety and / or healthcare quality strongly preferred.
• Just Culture certification and training strongly preferred.
• Certifications in Compliance and Risk Management strongly preferred.

Experience:

• Minimum of five (5) years experience in healthcare compliance, privacy, and regulatory requirements required.
• Clinical background in a hospital setting strongly preferred.
• Experience in leading and facilitating healthcare teams and projects.
• Exposure to, and experience with quality management techniques and tools.

Other Knowledge/Skills/Abilities:

• Advanced knowledge of accreditation standards (Joint Commission, CMS).
• Strong critical thinking skills, exceptional ability to integrate knowledge.
• Ability to interpret policies and procedures and apply them in specific situations.
• Demonstrates outstanding human relations skills, ability to effectively communicate and interact with all levels of professions.
• Must possess excellent observation, communication and decision-making skills, and strong problem solving and organizational skills.
• Work well under pressure and maintain professional demeanor under adverse conditions.
• Ability to work independently and to manage multiple tasks in a fast-paced environment.

1. Provides administrative direction for staff and operations regarding emergency preparedness, safety, accreditation, operations improvement, peer review, privacy, quality, compliance, risk management and medical staff affairs.

2. Serves as the Compliance and Privacy Liaison and Risk Manager.

3. Collaborates with respective MH Leaders to ensure appropriate identification and management of all quality, safety, compliance, and risk-related activities.

4. Provides administrative leadership to Patient Access, Patient Resources and Health Information Management.

5. Serves as a member of the Operations Management Team (OMT) and Medical Staff committees as appropriate and participates in the Administrator-On-Call rotation.

6. Assists and advises organizational leaders, physicians, and staff with identification, prioritization and improvement of operational and clinical process that will positively impact safety, quality, clinical effectiveness, regulatory compliance, privacy, and risk mitigation.

7. Conducts and/or oversees performance improvement projects to drive outcomes on key performance metrics including both process measures and outcome measures.
-Utilizes Lean Six Sigma techniques and project management skills to execute key initiatives
-Integrates with MH Operations Improvement black belt, project management and data science resources
-Completes process improvement projects to achieve the overall LMH targets and budgeted improvements

8. Ensures compliance with privacy practices and consistent application of sanctions for failure to comply with privacy policies for all individuals in the organization’s workforce, extended workforce, and for all business associates in cooperation with his/her immediate supervisor, Human Resources, the information security officer, and legal counsel as applicable.

9. Directs and leads all activities designed to meet or exceed Joint Commission and other regulatory accreditation on a continual basis.

10. Develops and implements risk identification systems and controls through appropriate analysis of incident trends and patterns.

11. Upholds the expectations for confidentiality of all patient information and other confidential business record information as job duties require full access to medical records.

12. Interprets and supports MH, LMH and departmental policies, objectives and operational procedures and represents these policies, objectives, and procedures in a positive, professional manner to all staff.

13. Provides regular communication and reports to MH and LMH leadership related to quality, safety, compliance, privacy, and risk management, including the LMH Board of Directors.

14. Encourages professional and personal growth of staff through the participation and involvement of in services and educational programs and keeps current with reading industry-related literature.

15. Coordinates the medical staff organization and its functions by scheduling, attending, and documenting medical staff committee meetings.

16. Facilitates the initial appointment and reappointment credentialing process for all applicants in a timely, accurate, and confidential manner in compliance with the medical staff bylaws and accrediting agencies’ standards.

17. Maintains the medical staff office and physicians’ credential files in a confidential, organized, current, and retrievable manner in accordance with accrediting agencies and hospital’s standards.

18. Acts as a resource person on medical staff issues, bylaws/rules and regulations, accrediting standards, state statutes, and other related issues as appropriate.

19. Maintains a continuous flow of information to the president of the medical staff, medical staff, and appropriate hospital personnel.

20. Performs other duties as assigned.

The intent of this job description is to provide a representative summary of the major duties and responsibilities performed by incumbents of this job. Incumbents may be requested to perform tasks other than those specifically presented in this description.