Transplant Quality and Compliance Coordinator

Job Profile Summary

This role focuses on developing and implementing programs to establish, maintain, and improve patient quality care standards. In addition, this role focuses on performing the following Performance Improvement/Quality duties:
Identifies and executes performance improvement and quality opportunities across the enterprise, enabling successful transformations and driving cost savings, process and product quality, and achievement of business goals. Responsibilities also include partnering with business leaders to provide expert insight on existing processes and procedures, applies process improvement methodologies to achieve PI/Quality objectives, and builds process improvement capabilities. A professional individual contributor role that may direct the work of other lower level professionals or manage processes and programs.

The majority of time is spent overseeing the design, implementation or delivery of processes, programs and policies using specialized knowledge and skills typically acquired through advanced education. An experienced level role that applies practical knowledge of job area typically obtained through advanced education and work experience. Works independently with general supervision, problems faced are difficult but typically not complex, and may influence others within the job area through explanation of facts, policies and practices.

This position develops, maintains, and oversees the Quality Management Plan for an assigned department and is responsible for all quality assurance, quality improvement, and regulatory compliance. This position will work directly with the Medical Director, Quality Management Director, and other clinical staff to ensure the highest quality of care and optimal patient outcomes.

• Bachelor of Science in Nursing (BSN) or another healthcare related field.
• Six (6) years of healthcare experience.
• Four (4) years of extensive work with healthcare technology and databases.

• Graduate degree.
• Eight (8) years of healthcare experience.
• Six (6) years of extensive work with healthcare technology and databases.
• Experience in quality/performance improvement.
• Experience in data analysis.

The duties and responsibilities listed below are intended to describe the general nature of work and are not intended to be an all-inclusive list. Other duties and responsibilities may be assigned.

• Ensures compliance with all applicable state and federal regulations and accreditations including the Foundation for the Accreditation of Cellular Therapy (FACT) and Joint Commission.
• Maintains, revises, and implements the Quality Management Plan (QMP) which provides the principles and tools for quality assurance, control, assessment, and improvement activities for the Program.
• Manages and maintains the document control system for the creation, review, revision, and implementation of standard operation policies and procedures
• Conducts, reviews, and reports audits of program clinical activities to verify compliance with and effectiveness of the Quality Management Plan.
• Collaborates with clinical staff to respond to audit findings and implement approved recommendations.
• Monitors and reviews error and accident reports, complaints and adverse events.
• Prepares agendas for QM meetings and coordinate activities related to the QMP in the clinical, apheresis and processing facilities of the Program to assure compliance with accreditation standards.
• Develops and maintains a system to document all staff qualifications, training, competencies, annual evaluations and CME activities
• Assists the Medical Director and FACT coordinator in preparing for FACT inspection and to maintain inspection readiness.
• Oversees the Program database and provides data management including data input, retrieval, and analysis.
• Prepares quality management and outcome reports for the assigned department.
• Completes and submits outcomes reporting forms to research databases.
• Assists with the completion of Request for Information (RFIs) for insurance providers.
• Supports the onboarding of new therapies and products for use in the department.
• Maintains meeting minutes.

• This is largely a sedentary role, which involves sitting most of the time, but may involve movements such as walking, standing, reaching, ascending/descending stairs, and operating office equipment.
• Frequently required to speak, hear, communicate, and exchange information.
• Ability to see and read computer displays, read fine print, and/or normal type size print and distinguish letters, numbers and symbols.
• Requires manual dexterity using fine hand manipulation to operate computer keyboard.

• Willingness to continue professional development through participation in relevant conferences, training and educational activities.
• Excellent written and oral communication skills.
• Strong analytical and problem-solving skills.
• Ability to conduct quality review,…