Job Abstract

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. • Oversee the maintenance of the OPTN data entry system for transplant centers (TIEDI) • Oversee 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. • Report, monitor and investigate risk/safety events that occur within the Transplant Institute. Develop and recommend corrective action plans, to improve patient quality and safety when undesirable patterns are identified. Actively participant in root cause analysis of sentinel events that occur within the Transplant Program. Communicate 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. • Develop and implement process to analyze and predict patient and graft survival as will be reported via SRTR cohorts. • Maintain collaborative, working relationship 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 monitor 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. • Work with transplant institute leadership and team to develop, review, revise and monitor policies, protocols, and forms to ensure best practice 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

• 2 years 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)

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. USC will consider for employment all qualified applicants with criminal histories in a manner consistent with the requirements of the Los Angeles Fair Chance Initiative for Hiring ordinance. 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.

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