Director of Quality and Compliance-

Job Summary:

The Director of Quality and Compliance is responsible for leading the development, implementation, and oversight of programs that ensure clinical excellence and regulatory compliance across the organization. This role plays a critical part in promoting safe, effective, and equitable care through performance improvement strategies, accreditation preparedness, and risk management. Working closely with senior leadership and clinical teams, the director ensures that all policies align with federal, state, and HRSA guidelines while driving continuous quality improvement initiatives.

Supervisory Responsibilities:

This position has direct supervisory responsibilities.

Essential Job Functions/Responsibilities:

• CORE FUNCTIONS
  1. Providing coordination, guidance, and support to practices and providers in developing and implementing quality initiatives that improve patient care.
  2. Providing project management support to ensure that initiatives involving people, processes, and technology are well-executed and aligned with organizational goals.
  3. Supporting the organization’s compliance with federal and state regulations and maintaining NCHC’s status as a Federally Qualified Health Center.
  4. Supporting external quality programs, including PCMH, Meaningful Use, and Vermont State initiatives.
  5. Collaborating with internal teams (providers, staff) and external stakeholders to drive improvement and maintain regulatory standards.
• QUALITY INITIATIVES RESPONSIBILITES
  1. Coordinates the implementation, monitoring, and revision of the organization’s Quality Improvement (QI) program.
  2. Supports staff in meeting regulatory accreditation and organizational compliance goals.
  3. Works with Information Systems staff to organize, compile, and report QI data to identify trends, set priorities, and recommend improvements.
  4. Reports findings to clinical directors and committees such as Utilization Review, Infection Control, and Risk Management.
  5. Organizes and/or conducts training to improve data quality and enhance patient care.
  6. Co-chairs and coordinates the activities of the Primary Care Quality Improvement Committee.
  7. Supports staff in efforts to enhance efficiency and quality of services across the organization.
  8. Assists with NCHC’s FTCA deeming process to ensure ongoing provider coverage.
  9. Performs other duties as assigned.
• COMPLIANCE OFFICER RESPONSIBILITIES
  1. The Compliance Officer oversees all aspects of the organization’s compliance program and is authorized to investigate suspected illegal or unethical conduct.
     • Oversees the development and implementation of the Compliance Program.
     • Directs initiatives to improve service quality and reduce fraud or abuse through audits, communication, and policy development.
     • Updates the Compliance Program based on changes in law, standards, or organizational needs.
     • Coordinates and leads compliance training for board members, staff, contractors, and representatives.
     • Ensures HR verifies all individuals and applicants against the OIG and GSA exclusion lists.
     • Investigates allegations of misconduct, implements corrective actions, and monitors outcomes.
     • Claims Coordination
       • Serves as the Claims Coordinator, managing all aspects of claims related to malpractice or litigation, including:
         1. Investigations, legal holds, and documentation.
         2. Coordination with legal counsel, staff, and external agencies.
         3. Timely processing and reporting of claims-related activities.
         4. Tracking claims trends and reporting to leadership and the Board.
         5. Reports regularly to the Senior Leadership Team and Board of Directors on compliance program activities.
• RISK MANAGEMENT RESPONSIBLITIES
  1. Serves as the Risk Manager under the direction of the Medical Director:
     • Oversees and coordinates daily risk management activities.
     • Participates in annual Risk Management training.
     • Collects and reports Unusual Occurrences to leadership and the Board.
     • Leads quarterly risk and QI/QA assessments.
     • Annually reviews and updates the Risk Management Plan.
     • Provides an Annual Risk Report and regular updates to the Board and Senior Leadership Team.

The above statements are intended to be a representative summary of the major duties and responsibilities performed by incumbents of this job. The incumbents may be requested to perform job-related tasks other than those stated in this description.

Position Qualifications:

• BS in Nursing, Public Health, Healthcare Administration, Business, or a related field is required. An associate degree combined with extensive relevant experience in nursing, quality, and/or compliance may be considered in lieu of a bachelor’s degree.
• Management experience in healthcare required, including training, supervision, personnel evaluation, and project management responsibilities.
• Must have a strong understanding, appreciation, and commitment to comprehensive community-based primary health care, including health care reform and quality initiatives.
• Must be effective in collaboration and communication with all staff.
• Demonstrated project management skills, including the ability to meet deadlines, deliver results, make quality decisions, take responsibility for outcomes, and adapt to changing conditions while adding value beyond the scope of the position.
• Ability to solve problems collaboratively with staff.
• Ability to advocate for NCHC while interfacing with outside professional organizations.
• Self-motivated and able to work independently.
• Demonstrates initiative, sound professional judgment, and the ability to work well with others.
• Excellent written and verbal communication skills required.
• Must maintain a high level of confidentiality.
• Proficient in computer applications including word processing, spreadsheets, databases, department-specific software, and email.
• Requires prolonged sitting, some bending, stooping, and stretching.
• Requires eye-hand coordination and manual dexterity sufficient to operate a keyboard, photocopier, telephone, calculator, and other office equipment.
• Requires normal range of hearing and eyesight to record, prepare, and communicate appropriately.
• Proficient in written and verbal communication.
• Computer proficiency, including email, spreadsheets, word processing, and EMRs
• High level of confidentiality required
• Physically able to lift up to 50 pounds and stand/walk for extended periods
• Manual dexterity and hand-eye coordination required
• Exposure to bodily fluids and communicable diseases expected
• May require occasional lifting up to 25 pounds.

This is an exempt, full-time leadership position offering the opportunity to make a meaningful impact on healthcare quality and compliance in Vermont’s Northeast Kingdom.