Director of Compliance and Quality

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Job Summary

The Director of Compliance and Quality is a member of the Senior Leadership Team (SLT) and works with the SLT, management, clinical and administrative staff in all departments to monitor and evaluate the quality of patient care, organizational performance on quality metrics, patient and staff safety, risk assessment and mitigation, and compliance with requirements of funding, regulatory, contractual, and accrediting entities. The Director manages a team of provider educators and population health coordinators to carry out evaluation of services, data analysis, research, and implementation of special projects to meet HFHC goals for quality and performance and to support organizational growth.

Qualifications / Requirements

  • A minimum of five years of experience in continuous quality improvement, rapid cycle change processes, and risk management in a healthcare setting.
  • Graduate degree in a healthcare field.
  • Graduate-level education in Healthcare Risk Management.
  • Excellent leadership skills and ability to work effectively with a diverse multidisciplinary team of health care professionals and support staff.
  • Ability to delegate responsibilities and create a climate of teamwork and accountability.
  • Above-average oral and written communication skills.
  • Ability to manage multiple and simultaneous responsibilities and to prioritize scheduling of work.
  • Excellent internal and external customer service skills.
  • Knowledge of adult learning methodologies and ability to design and deliver professional training.
  • Computer skills including Microsoft Office applications.
  • Understanding of the intent, and ability to follow standards, guidelines and protocols related to regulatory, legal, and accreditation standards and requirements.
  • Must demonstrate personal and professional commitment to the mission of Heart of Florida Health Center and its Mission Statement and values.

Leadership Qualifications / Requirements

  • Responsible for representing the organization to official agencies..
  • Must be able to serve on interview panels and independently judge qualifications of applicants for assorted positions as requested.
  • Must serve on the Senior Leadership Team (SLT) and assist other departments as needed.
  • Must be able to adhere to budgetary requirements of the department, adjusting as needed to maintain accountability to CEO.


Full Benefits package includes medical, dental, vision, life, short- and long-term insurances, generous PTO from the onset, 11 paid holidays, 401K with up to 5% match and much more!


Essential Functions

  • Monitor key performance indicators including HEDIS and UDS, and work with other senior leadership to implement process and systems-level improvements to attain targets.
  • Facilitate monthly meetings with Quality Team, Population Health Team, and Compliance and Risk Management, including preparing agendas and minutes, monitoring action items, and promoting communication.
  • Manage, address, and track formal grievances and complaints from patients, family members, and other community stakeholders, to improve patient and family satisfaction and successful relationships with funders and the community.
  • Manage internal incident reporting and investigations. Track and report trends to identify areas of actual or potential risk and support a culture of safety.
  • Participate in monthly and ad hoc meetings with managed care insurances to review performance on HEDIS measures.
  • Serve as a resource for other members of the Senior Leadership Team on issues related to policies, compliance, risk, contracts, and quality. Provide support, guidance, and assistance with a range of problems.
  • Develop and maintain policies and procedures related to QI and Risk Management to provide guidance to staff and assure compliance with HRSA, FTCA, and PCMH standards.
  • Review and process subpoenas and court orders for patient records, to assure compliance with HIPAA and other state and federal regulations.
  • Keep PCMH accreditation current, collect and submit performance data on the core and selected optional standards.
  • Maintain current knowledge of relevant laws and requirements to assure compliance in policies and procedures, strategic planning, and risk mitigation.
  • Report on quality, risk, and population health data to the Board, as required by HRSA and to assist Board members in effective and knowledgeable governance.
  • Represent HFHC in community organizations and boards, as approved by the CEO, to strengthen HFHC presence at the county and state levels, develop collaborations to improve population health, identify opportunities for growth, enhance advocacy efforts, and maintain HFHC’s reputation as a valuable resource and partner.
  • Write and update corporate QI and risk management plans to meet HRSA and FTCA standards, guide department activities, assure alignment with the HFHC strategic plan, and provide benchmarks to evaluate department performance.
  • Review contracts and agreements as requested and recommend any modifications based on compliance and potential costs and benefits to HFHC.
  • Collaborate with Director of Grants Administration to gather and submit data, policies, and documentation for FTCA reapplications.
  • Develop and disseminate annual risk management training to staff and Board, in person or through the online training system, to assure staff understand incident reporting, a culture of safety, areas of risk, risk mitigation, and FTCA.
  • Maintain updated Continuity of Operations Plan and write After Action reports following disaster drills or actual events, to better prepare staff and acquire resources needed for emergencies, resume normal operations ASAP, and mitigate loss.
  • Participate in multi-organizational learning collaboratives related to population health, to improve service delivery and outcomes by implementing current and best practices.
  • Prepare and organize documentation for Operational Site Visits and ensure any corrective actions are submitted prior to the final report.
  • Participate in regional and national organizations (e.g., FACHC and NACHC).
  • Serve as a member of the Leadership Team.
  • Other duties and tasks as assigned by the CEO.

Physical Requirements

While performing the duties of this job, the employee is regularly required to talk and hear.  This position is very active and requires standing, walking, bending, kneeling, and stooping throughout the day, but may also involve long periods of sitting or computer-based work.

This employee must frequently lift and/or move items over 30 pounds but must use a team-lift approach to prevent injury.  Must be able to lift, carry and handle equipment, supplies and other work site materials according to position requirements.

This position may also involve travel, including occasional overnight stays, to meetings, conferences, and other corporate requirements.

The Population Served

As part of the Patient Centered Medical Home Model of care, the employee will advocate for patient’s best interest and make recommendations for patient special needs such as interpreter services; identified barriers to care such as transportation, medication assistance, outreach, and health education; influence patient’s engagement in their care; promoting a continuum of safe, quality, and cost-effective patient care.

Mission Statement

Our mission is to improve the overall health status of Marion County residents by providing quality primary medical, dental and mental health services to all residents, but in particular to those residents who would not otherwise be able to access the services due to financial limitation and/or lack of health insurance.

Core Values

Integrity * Quality * Respect * Collaboration * Compassion

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