SCOPE OF POSITION
The Senior Clinical Compliance Staff Specialist reports to the Senior Director of Clinical Compliance and participates in clinical compliance activities within the MGH/MGPO Corporate Compliance Office. He/she is an essential resource in assisting the Senior Director with ongoing regulatory preparedness within the General Hospital and Physicians Organization. In accomplishing his/her activities, the Senior Clinical Compliance Staff Specialist is authorized to have full, free and unrestricted access to all General Hospital and Physicians Organization functions, records, property and personnel relevant to the subject under review.
PRINCIPAL DUTIES AND RESPONSIBILITIES
Participates in risk assessments concerning the regulatory challenges facing the General Hospital and Physicians Organization in the clinical compliance arena including compliance with regulations and standards promulgated by the Centers for Medicare and Medicaid Services, Department of Public Health, Department of Mental Health, The Joint Commission, and other regulatory and accreditation organizations.
Contributes to the MGH/MGPO clinical compliance tracer program to ensure ongoing measurement of MGH/MGPO performance in key clinical compliance risk areas. Assists with collecting ongoing results of this program that will be presented to organizational leadership consistent with and in support of the MGH/MGPO Quality Assessment and Performance Improvement program.
Participates in clinician training programs where necessary in areas of clinical compliance deficiency identified through risk assessments, clinical tracers, regulatory surveys and other sources.
Assists department chiefs, the chief nursing officer, and other clinical leadership and their desigees in addressing clinical compliance issues within their areas of responsibility. Ensures consistency in compliance efforts within the General Hospital and Physicians Organization as well as ensuring clinical compliance efforts are consistent with and in support of the Mission, Credo and Boundaries statements of the General Hospital and Physicians Organization.
Ensures timely completion and filing of DPH Serious Reportable Events and other mandatory reporting requirements within the clinical compliance arena. Serves as MGH/MGPO liaison to the Partners Clinical Compliance Committee. Represents MGH/MGPO clinical compliance on the Quality and Patient Safety Committee.
Investigates reported non-compliance and resolves problems on a timely basis.
Recommends modifications to overall clinical compliance efforts to enhance effectiveness.
Establishes goals and objectives for the clinical compliance program; determines policies and practices for clinical compliance auditing and monitoring activities.
Understanding of CMS, DPH, DMH, TJC and other regulatory organizations' regulations and standards preferred.
Demonstrated success in developing and implementing clinician training programs.
Strong analytic skills and high degree of comfort in working with data and data complexities.
Aptitude for work in an organized, detail-oriented, and timely manner.
Ability to work both collaboratively and independently.
Ability to interact effectively with senior leadership and a wide range of stakeholders.
High degree of professionalism and discretion.
High degree of service orientation.
QUALIFICATIONS Bachelor's degree required (Masters preferred) in nursing, or other clinical discipline.
3-5 years of directly related experience required including project management/quality and safety, coordinating regulatory and accrediting organizations' unannounced on-site surveys, and in developing corrective action plans in follow up to identified deficiencies.
3-5 years experience in an academic medical center with a faculty practice plan preferred.
Mass General is committed to diversity among its employees and encourages qualified candidates from all backgrounds to apply.
By embracing diverse skills, perspectives and ideas, we choose to lead. Applications from protected groups such as veterans and individuals with disabilities are strongly encouraged to apply.
Partner's Healthcare is acting as an Employment Agency in relation to this vacancy.
Position Type: Full-Time Permanent
Years of Experience Required: