Finance Director

Regional Quality Assurance and Risk Manager

The primary purpose of your job position is to plan, organize, develop, coordinate and direct our facility’s Quality Assessment, Risk and Assurance Program in accordance with current applicable federal, state, and local standards, guidelines and regulations, and as may be directed by the administrator and director of nursing to assure that the highest degree of quality resident care and safety can be maintained at all times. The person in this position is required to have Quality Assurance and Risk Training.

Delegation of Duty:

As the Quality Assessment and Risk Manager, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties.

Job Functions:

Every effort has been made to identify the essential functions of this position. However; it in no way states or implies that these are the only job duties you will be required to perform. The omission of specific statements of duties does not exclude them from the position if the work is similar, related or is an essential function of the position.

• Plan, organize and direct quality assurance and risk programs and activities.
• Plan, develop, organize, implement, coordinate, and direct the quality assurance, risk and assessment program designed to enhance the quality of resident care, in accordance with current rules, regulations, and guidelines that govern nursing care facilities.
• Evaluate programs and effect changes as necessary to improve programs and assure compliance with regulatory requirements.
• Communicate revised plans and changes to facility management to maintain awareness.
• Coordinate concurrent review studies performed within the quality assurance program, prepare resulting reports as required.
• Establish and maintain tracking systems for recommendations of groups involved in quality assurance.
• Develop and implement appropriate plans of action to correct identified deficiencies.
• Perform administrative requirements such as completing necessary forms, reports, etc., and submitting to the administrator and director of nursing as required.
• Represent the facility at and participate in meetings as directed.
• Conduct Quality Assurance and Performance Improvement Program and maintain all aspects of the program.
• Conduct Risk Assessment meeting and maintain files.
• Maintain an adequate liaison with families and residents.
• Participate in On-Call phone rotation with other nursing staff.
• Assist with working on medication cart as directed by the director of nursing and administrator.
• Daily rounding to help assist identifying any Potential Risks.
• Schedule committee meetings and notify members of such meetings.
• Assist in developing follow-up procedures for monitoring identified problem areas.
• Maintain a reference library of written quality assessment, risk and assurance material, laws, etc., necessary for complying with current standards and regulations that will assist in maintaining quality resident care.
• Assist with monthly benchmark reports.
• Make written and oral reports/recommendations to the administrator and director of nursing as necessary/required, concerning the operation of the quality assessment, risk and assurance program.
• Assume the authority, responsibility and accountability of directing the quality assessment, risk and assurance department.
• Manage Incidents/Accidents (Risk Management), including resident, visitor, and staff claims.
• Assist with completing Reportable incidents, and follow-up documentation.
• Assist in developing yearly evaluation schedules for departmental studies.
• Assist with Pharmacy Recommendations.
• Assist in identifying and classifying procedures in which potential exposure to blood/body fluids may occur, update as necessary.
• Run and Manage Weekly Risk Meeting and maintain committee minutes of meetings.
• Agree not to disclose assigned user ID code and password for accessing resident/facility information and promptly report suspected or known violations of such disclosure to the administrator and director of nursing.
• Agree not to disclose resident’s protected health information and promptly report suspected or known violations of such disclosure to the administrator and director of nursing.
• Report any known or suspected unauthorized attempt to access facility’s information system.
• Review the facility’s quality indicator reports, quality measures and survey reports to assist in identifying potential problem areas.
• Make reports to committee as necessary.
• Assist in developing plans of action and correction of identified problem areas.
• Participate in facility surveys as necessary or as may be directed.
• Work with the facility’s in reviewing policies and procedures, survey reports, etc., to ensure protocols are in place to aid in loss prevention.
• Others as deemed necessary and appropriate, or as may be directed by the administrator of director of nursing.
• Serve as chairperson of the Quality Assessment, Risk and Assurance Committee.
• Meet with the Quality Assessment, Risk and Assurance Committee monthly to review all assessment tools designed, all data collections reports, and all activities regarding quality assurance as carried out by departments, services, or committees that have a direct impact on resident care and safety.
• Attend various committees of the facility (i.e. Pharmacy Committee, Safety Committee, QAPI, Risk, Resident Care Policy Committee, etc.) as deemed appropriate, and as appointed by the administrator and director of nursing.
• Assist other committees and departments in the development of monitoring tools, criteria and standards, assessment methodologies, and the evaluation and selection of priority concerns impacting on resident care and safety.
• Assist with identifying and reporting positive infections to the proper state, and federal authorities.
• Serve as liaison among committees and/or departments to focus on quality assurance and risk in the ongoing operation of the facility.
• Implement recommendations from the Quality Assessment, Risk and Assurance Committee as they relate to the quality assurance and risk program.

Personnel Functions:

• Report known or suspected incidents of fraud to the administrator and director of nursing.
• Ensure that departmental computer workstations left unattended are properly logged off or the password protected automatic screen-saver activates within established facility policy guidelines.

Staff Development:

• Develop and participate in programs designed for in-service education, on the job training and orientation classes for newly assigned personnel. (Includes maintaining appropriate recordkeeping requirements of when classes were held, subject matter, attendance, etc.).
• Develop, implement and maintain an effective orientation program that orients the new employee to the facility, its policies and procedures, and to his/her job position and duties.
• Monitor and supervise work, evaluate performance and initiate or recommend personnel action such as merit increases, promotions, and disciplinary action.
• Participate and assist in departmental studies and projects as assigned or that may become necessary.
• Attend and participate in workshops, seminars, etc., to keep abreast of current changes in the health care field, as well as to maintain a professional status.

QUALITY ASSURANCE AND RISK MANAGER

• Attend and participate in annual facility in-service programs (e.g. OSHA, TB, HIPAA, Abuse Prevention, Safety, Infection Control, etc.).
• Assist the in-service director/educator in identifying areas in which training is needed.

Budget and Planning Functions:

• Prepare ad plan the quality assessment, risk and assurance department’s budget and submit to the administrator of his/her review, recommendation, and/or approval.
• Keep abreast of economic conditions/situations and recommend to the administrator and director of nursing adjustments that ensure the continued ability to provide quality care.
• Report suspected or known incidence of fraud relative to false billings, cost reports, kickbacks, etc.

Resident Rights:

• Maintain the confidentiality of all resident care information including protected health information.
• Report known or suspected incidents of unauthorized disclosure of such information.
• Knock before entering a resident’s room, introduce yourself and ask if you can enter.
• Ensure that all quality assessment, risk and assurance personnel are knowledgeable of resident rights and responsibilities, including the right of refusal.
• Ensure that residents rights to fair and equitable treatment, self-determination, individuality, privacy, property and civil rights including the right to wage a complaint, are well established and maintained at all times.