Manager, Quality & Compliance - Transplant Administration -Full Time 8 Hour Days (Exempt) (Non-[...]
Company: University of Southern California
Location: Los Angeles
Posted on: October 16, 2024
Job Description:
Manager, Quality & Compliance - Transplant Administration - Full
Time 8 Hour Days (Exempt) (Non-Union)
Locations: Los Angeles, CA - Health Sciences Campus
Time Type: Full time
Posted on: Posted Yesterday
Job Requisition ID: REQ20147083
The Manager of Quality and Compliance is responsible for leading
and maintaining the regulatory compliance and process improvement
initiatives of the transplant institute as set by the Organ
Procurement Transplant Network (OPTN) / United Network for Organ
Sharing (UNOS), CMS, Joint Commission, Intermacs, and the ESRD
Network. This position will lead and assist in the implementation
of all the elements of an effective transplant quality program
which includes leading the Multi Organ Transplant Committee (MOTC),
policy development, monitoring auditing, process improvement
initiatives and supervise the Transplant Quality specialists. In
addition, the Manager of Quality and Compliance is expected to
provide technical expertise and education to management, staff, and
physicians regarding regulatory transplant compliance issues. This
position will also serve as a key stakeholder and provide oversight
during regulatory reviews and surveys. This position reports
directly to and collaborates closely with the Associate
Administrator of the Transplant Institute.
Essential Duties:
- Compliance: Compiles survey findings to create and develop
related plans of correction. Maintains policy and procedures to
support alignment with regulatory requirements and works with
program leadership to support alignment with program practice.
Prepares and maintains materials/documents used for surveys by CMS,
UNOS, and Joint Commission. Leads and participates in the
preparation of corrective action plans in response to regulatory
surveys and to internal and external reported events. Coordinates
scheduling of announced visits/surveys and participates in the
survey process in collaboration with transplant institute leaders
and the hospital quality teams. Leads and contributes to the
transplant institute leaders and staff to assure continuous survey
readiness with policy and procedure development, review and
revision, mock survey drills, and ongoing education. Monitors and
tracks compliance with UNOS requirements for data submission. Works
with management and applicable staff if there is not full
compliance. Develop and complete audits as needed in order to
assess compliance. Primary interface with regulatory agencies (CMS,
Joint Commission, Intermacs - as applicable). Maintains current
working knowledge of requirements related to CMS conditions of
Participation, Joint Commission Disease Specific Certification for
VAD, OPTN/UNOS Policies and Bylaw, PHS Increased Risk Guidelines,
and any other transplant standards, guidelines, and
recommendations. Collaborates in a proactive manner with the USC
Health System community hospital entities' management teams, staff
and physicians regarding compliance risks, controls and new
developments in transplant compliance laws and regulations.
Provides subject matter expertise on transplant compliance matters
and recommends responses/procedures related to the laws,
regulations, and program guidance for Medicare, Medi-Cal and other
regulated payers.
- Reports and Policy Preparation and Administration: Coordinates
preparation of UNOS reports including annual personnel report,
changes in key personnel and reports requested by the Membership
and Professional Standards Committee. Oversees the maintenance of
the OPTN data entry system for transplant centers (TIEDI). Oversees
the accurate reporting of all graft losses and patient deaths via
TIEDI in a timely manner. Creation of departmental policy in
collaboration with administration and Transplant Institute
leadership, as well as policy revisions. Responsible for keeping up
with UNOS/OPTN policy/bylaw and CMS regulations and ensuring
Transplant Institute policy is in compliance and aligned with the
regulations. Revises documentation forms and consent forms as
indicated. Serves on committees and peer networks as appropriate.
Leads and coordinates development and preparation of quality
reports and Quality Plans for all Transplant Programs and the VAD
program. Leads the Multi Organ Transplant Committee Dashboard
maintenance efforts. Leads the MOTC quarterly meetings and follows
up on any recommendations or feedback from hospital and program
leadership. Assists in the completion of UNOS/insurer's RFI on an
annual basis in collaboration with the program managers and program
medical directors. Oversees the ongoing medical record reviews,
including reviews of documentation required for CMS and UNOS. Organ
Transplant Database super user. Assists with business development
and financial initiatives.
- Performance Improvement: Leads and participates in the planning
and implementation of systematic processes to improve the quality
and safety of patient care, and operational effectiveness of the
transplant institute. Reports outcomes, opportunities for
improvement, and best practices to the designated transplant
program(s), Transplant Institute leadership and / or hospital
committees as requested. Reports, monitors and investigates
risk/safety events that occur within the Transplant Institute.
Develops and recommends corrective action plans to improve patient
quality and safety when undesirable patterns are identified.
Actively participates in root cause analysis of sentinel events
that occur within the Transplant Program. Communicates events and
findings with Transplant Institute leadership and appropriate
staff. Supports and coordinates Adverse Event Reviews and Morbidity
and Mortality Conferences in collaboration with the physician
leadership. Develops and implements processes to analyze and
predict patient and graft survival as will be reported via SRTR
cohorts. Maintains collaborative, working relationships across the
healthcare continuum and disciplines involved with transplant
patients including the OR, VIO, and various patient units within
Keck Hospital of USC. Coordinates organ offer review meetings on a
regular basis and monitors organ declines in collaboration with the
Transplant Call Team and transplant physician leadership. Annually
revises the Performance Improvement Indicators defined for each
program and makes recommendations for revisions for the upcoming
year. Works with transplant institute leadership and team to
develop, review, revise and monitor policies, protocols, and forms
to ensure best practices to standardize clinical care, reduce
practice variation, and to ensure effective workflows.
- Leads and coordinates the QA Transplant Program's regularly
scheduled meetings and ongoing education.
- Perform other duties as assigned.
Required Qualifications:
- Bachelor's degree OR
- Minimum of 2 years in Transplant environment and/or transplant
quality assessment and performance improvement.
- 5 years Supervisory position in an acute care setting.
- Well versed in CMS regulations and OPTN/UNOS policies and
bylaws.
- Demonstrates strong leadership, organizational and project
management skills.
- Effective personal and professional written and verbal
communication skills.
- Work effectively with hospital leaders, physicians, and
transplant team, as well as multidisciplinary staff across clinical
and non-clinical areas.
- Proficient in Word, Excel, PowerPoint, and Internet
applications.
- Demonstrates customer service values.
- Strong knowledge of healthcare trends in transplantation and
quality improvement concepts.
- Strong analytical and problem-solving skills.
- Strong critical thinking and decision-making skills.
Preferred Qualifications:
- Master's degree
- Certified Professional in Healthcare Quality - CPHQ (NAHQ) Or
Lean Six Sigma
Required Licenses/Certifications:
- Fire Life Safety Training (LA City) If no card upon hire, one
must be obtained within 30 days of hire, and maintained by renewal
before expiration date. (required within LA City only)
The annual base salary range for this position is $110,240.00 -
$181,896.00. When extending an offer of employment, the University
of Southern California considers factors such as (but not limited
to) the scope and responsibilities of the position, the candidate's
work experience, education/training, key skills, internal peer
equity, federal, state, and local laws, contractual stipulations,
grant funding, as well as external market and organizational
considerations.
USC is an equal opportunity, affirmative action employer. All
qualified applicants will receive consideration for employment
without regard to race, color, religion, sex, sexual orientation,
gender identity, national origin, protected veteran status,
disability, or any other characteristic protected by law or USC
policy.
We provide reasonable accommodations to applicants and employees
with disabilities. Applicants with questions about access or
requiring a reasonable accommodation for any part of the
application or hiring process should contact USC Human Resources by
phone at (213) 821-8100, or by email at uschr@usc.edu. Inquiries
will be treated as confidential to the extent permitted by law.
Read USC's Clery Act Annual Security Report
Certain positions are subject to background screening
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About Us
USC is a leading private research university located in the heart
of downtown Los Angeles - a global center for arts, technology and
international business.
As the largest private employer in the city - responsible for more
than $5 billion annually in economic activity in the region - we
offer the opportunity to work in a dynamic and diverse environment,
in careers that span a broad spectrum of talents and skills. As a
USC employee, you will enjoy excellent benefits and perks, and you
will be a member of the Trojan Family - the faculty, staff,
students and alumni who make USC a great place to work.
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Keywords: University of Southern California, Lancaster , Manager, Quality & Compliance - Transplant Administration -Full Time 8 Hour Days (Exempt) (Non-[...], Executive , Los Angeles, California
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