POSITION SUMMARY

The Director of Quality will be responsible for all quality and quality assurance performance improvement activities within JMHS. The Director of Quality will ensure that all quality activities within the organization are achieved according to federal and state regulations. The Director of Quality will also serve as the HIPAA (Health Insurance Portability and Accountability Act) Privacy Officer and will oversee all HIPAA activities, training, and review of any HIPAA privacy concerns or breaches. The Director of Quality will demonstrate behaviors that align with Johnson Memorial Health Services’ Core Values: Together, Kindness, and Trust.

Essential Duties

The Director of Quality / Privacy Officer will be responsible for the following:

• Assist with QIPI & PIPP projects
• Knowledge of privacy regulations and enforcement of them
• Organize and keep records of Professional Activities Committee (PAC) meetings
• Serves as facility liaison to the JMHS Accountable Care Organization
• Facilitate and keep records of quarterly Quality Assurance department meetings and Quality meetings of the JMHS Board of Directors
• Facilitate and keep records of monthly Care Center QAPI meetings
• Facilitate and keep records of quarterly Assisted Living Quality Assurance Meetings
• Gather and maintain statistical reports for clinic, hospital, and senior living
• Prepare quality reports for medical staff and the Board of Directors
• Provide assistance to department managers with their departmental quality reporting
• Attend local meetings offered by Medi-Sota and MN Rural Health Cooperative and other trade associations as directed
• Participate in and/or lead specific projects and other duties as assigned.

QUALIFICATIONS & REQUIREMENTS

Education and Experience

• Associate/bachelor’s degree in Nursing, Business, or related field. (Required)
• 3-5 years of experience in staff management and leadership (Required)
• 3-5 years of experience in Quality Assurance in a healthcare setting and Quality Certification (Preferred)
• Knowledge and experience using EPIC EHR (Preferred)
• Knowledge of HIPAA privacy regulations and how to apply them (Preferred)

 Required Licenses

• Registered Nurse (RN) or Licensed Practical Nurse (LPN) is preferred but not required.

 Skills, Abilities, and Knowledge

• Knowledge of information systems and healthcare applications
• Knowledge of medical terminology
• Knowledge and experience in computer applications (Windows, MS Office, etc.)
• Knowledge and experience of rules and regulations regarding the medical staff
• Ability to serve in a leadership position
• Knowledge and understanding of diagnosis and procedure coding as it relates to Minnesota Community Measures and HCAHPS
• Knowledge of external regulations that affect areas of responsibility, including CMS 5-star reporting and MN Nursing Home star rating criteria
• Strong oral and written communication skills
• Demonstrates a high degree of commitment to customer service excellence
• Ability to work effectively with internal and external stakeholders, building strong relationships
• Ability to perform tasks both collaboratively and independently
• Maintains confidentiality of information and privacy compliance

Travel

• Minimal travel may be required up to 5%

SUPERVISOR RESPONSIBILITIES

• This position has no supervisory responsibilities.

The foregoing statements describe the general purpose and responsibilities assigned to this job and are not an exhaustive list of all responsibilities and duties that may be assigned or skills that may be required.

JHMS is committed to the full inclusion of all qualified individuals. As part of this commitment, JHMS will ensure that persons with disabilities are provided reasonable accommodations. If reasonable accommodation is needed, please contact the Human Resources Department. JMHS is an equal opportunity employer. All applicants will be considered for employment without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran, or disability status.