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   Current UPMC employees must apply in HR Direct

Senior Director Quality, Education and Compliance

Description

Purpose:
The Sr. Director reports to the CEO for Senior Communities (SRC). Works closely and collaborates with the clinical leadership to assure clinical care standards within UPMC Senior Communities skilled nursing and personal care facilities are maintained with the expectation of ensuring high standards of care while maintaining the facilities in compliance with regulatory agencies. The Sr. Director manages and coordinates in concert with the COO, SRC organization-wide effort to ensure quality care and regulatory compliance using a risk-based and data-driven focus that sets priorities for education aligned to ongoing strategic goals, regulatory requirements and organizational initiatives.  The Sr. Director also provides general oversight for infection control in conjunction with the Sr. Infection Preventionist and the Wolff Center. Monitors, analyzes and reports on a variety of data to assess the quality and appropriateness of care and facilities' performance and provides oversight and guidance for ongoing improvement efforts within the QAPI framework. Collaborates with all facilities, departments and Senior Leadership to mentor, educate and motivate staff surrounding data-driven performance improvement initiatives and regulatory requirements. Develops and fosters effective two-way communication of current trends, regulatory changes and QA/PI projects. Facilitates ongoing development and monitoring of capabilities to assure federal and state compliance throughout all facilities. Functions as the Privacy Officer for Senior Communities.  The Sr. Director will have high visibility and interaction with the Chief Quality Officer.

Responsibilities:

  • In conjunction with the Chief Quality Officer, the Sr. Director will collaborate with the Donald D. Wolff, Jr. Center for Quality, Safety, and Innovation.
  • Assures maintenance and development of clinical skills among the staff, through coordination of specific programs.
  • Educates and evaluates staff compliance with policies and procedures related to nursing practices and all senior communities operational areas.
  • Develops, maintains and evaluates organizational systems that support attainment of regulatory compliance, with a focus on minimizing deficiencies and fostering an environment of Survey Readiness and achieve optimal 5 Star ratings.
  • Directs mock survey processes and related tool sets designed to identify issues and concerns.
  • Maintains active and current knowledge of CMS, DOH and DHS requirements for skilled nursing and assisted living facilities respectively.
  • Represents SRC at UPMC Compliance Officer, Privacy Officer, Regulatory Expert and Quality Meetings regularly held to provide education and awareness.  Brings the education back to SRC and measures the effectiveness of understanding.
  • Uses regulatory development, facility-based findings, clinical program needs and feedback from facility operational leadership to identify educational needs whether facility specific or SRC-wide.
  • Supports the UPMC SRC standards of practice in the implementation of education and clinical programs.
  • Acts as a long term care privacy officer, compliance officer and regulatory resource for UPMC.
  • Develops implements and monitors the QAPI process for the skilled nursing facilities.
  • Ensures organizational compliance with CMS (and other regulatory agencies) regulations and reporting requirements.
  • Fosters facility preparation for CMS surveys with a focus on continual survey readiness.  Leads & monitors mock survey functions for skilled nursing, assisted living and personal care facilities.
  • Creates an environment of quality assessment and performance improvement, regulatory compliance and clinical excellence. Communicates timely factual, objective, quantifiable Quality and Regulatory compliance reports to SRC Senior Leadership.  Tracks and communicates survey results, complaint investigations, scope and severity trends, and remedies to determine accurate decisions related to intervention strategies. Trends and analyzes quality outcomes and related system improvement opportunities for organizational quality assurance and performance improvement. Ensures identification of clinical data metrics for analysis of overall quality of care and Regulatory compliance.
  • Develops monitoring and reporting process for Quality Measures and CMS 5 Star performance.
  • Facilitates ongoing efforts to achieve and maintain optimum CMS Star rating.
  • Develops, implements, and monitors clinical care programs to meet the bundled payment process and improve clinical management through implementation of evidence-based best practices.
  • Oversees Case Mix Index and RUGS to assure revenue is aligned with clinical documentation and resident care needs.
  • Collaborates on the design of the information technology infrastructure required to support QA/PI efforts.

 

Qualifications

  • RN required
  • Bachelors in Nursing required
  • Master's degree in Nursing or related health care field required, either at time of hire/transfer, or must be enrolled in a program within one year of hire/transfer date and completed within three years of enrollment. (i.e. public health, informational technology, administration, etc.)
  • 2-3 years of experience in acute care required
  • 5 years of experience in Skilled and or Personal Care required
  • Nursing Management experience in acute and or Long Term Care required
  • Long term care Nursing Education, Quality and Compliance required
  • NHA License, preferred


Licensure, Certifications, and Clearances:
CPR required based on AHA standards that include both a didactic and skills demonstration component within 30 days of hire
 

  • Basic Life Support (BLS) OR Cardiopulmonary Resuscitation (CPR)
  • Registered Nurse (RN)
  • Act 34
  • OAPSA

  • UPMC is an Equal Opportunity Employer/Disability/Veteran

Total Rewards

More than just competitive pay and benefits, UPMC’s Total Rewards package cares for you in all areas of life &emdash; because we believe that you’re at your best when receiving the support you need: professional, personal, financial, and more.

Our Values

At UPMC, we’re driven by shared values that guide our work and keep us accountable to one another. Our Values of Quality & Safety, Dignity & Respect, Caring & Listening, Responsibility & Integrity, Excellence & Innovation play a vital role in creating a cohesive, positive experience for our employees, patients, health plan members, and community. Ready to join us? Apply today.

   Current UPMC employees must apply in HR Direct