Standards Compliance Officer

TX-HHSC-DSHS-DFPS • Rusk, TX

2d • Onsite

About The Position

Would you thrive in an environment where you learn and grow personally and professionally all while helping make a positive impact on people’s lives? Do you appreciate being around others like yourself who are dependable, trustworthy, hard workers who believe in the value of teamwork? HSCS is dedicated to building an atmosphere where employees feel valued and supported while providing specialized care for Texans in need. HSCS is comprised of eleven psychiatric hospitals, two youth residential treatment facilities, and thirteen state supported living centers. Psychiatric hospitals are a hub of excellence for forensic mental health and complex psychiatric care, with all facilities accredited by The Joint Commission. They provide state-of-the-art treatment that is recovery-oriented and science-based. If providing hope and healing through compassionate, innovative, and individualized care interests you, we welcome your application for the position below.

The Manager II (Standards Compliance Officer) performs moderately complex (journey-level) managerial work administering the daily operations and activities of an agency’s business function, division, or department. Works under general supervision, with limited latitude for the use of initiative and independent judgment. Requires specialized knowledge in planning, development, implementation, and monitoring of quality assurance systems. Ensures the facility conforms to the conditions of participation for the facility as a Centers for Medicaid and Medicare Services (CMS) provider serving persons with mental health diagnoses, the Joint Commission (TJC) standards, and all other relevant state and federal laws, rules, and regulations.
Interprets regulations/standards, develops, and disseminates policy, performs advanced consultative services to program staff, and coordinates a comprehensive system of implementing and reporting on quality enhancement efforts. Oversees assigned indicators including monitoring, data collection, analysis, presentation, and hospital wide reporting of the same through the hospitals committee structure. Serves as a member, facilitator, or consultant on assigned hospital standing committees including Pharmacy and Therapeutics, Environment of Care, Performance Improvement, Risk Management, and Medical Executive. Facilitates special projects as assigned by hospital leadership. Works closely with hospital leadership and committees in evaluating and improving the clinical safety program at the hospital. Coordinates and oversees activities of and participates in the development and implementation of the hospital Clinical Safety Program including proactive assessments of patient safety concerns and determination of standards compliance, development and oversight of the collection, analysis, and reporting of data related to clinical safety, and participates in various hospital committees assigned. Serves as the primary consultant and active participant on Root Cause Analysis, Management Initiated Reviews, and Proactive Risk Assessments. Monitors plan of correction for Management Initiated Reviews and Root Cause Analysis and maintain tracking mechanisms to track trends and to ensure all are completed in a timely manner. Makes recommendations related to trends in data. Participates in the development of staff education related to patient safety concerns. Supports the hospital’s overall Joint Commission and CMS survey and continuous readiness activities. Must understand that the duties, location of work and shift pattern are subject to change as determined by administration in order to meet department and hospital needs. Must understand that the duties may include exposure to blood or other potential infectious materials. Employee actively participates and/or serves in a supporting role to meet the agency's obligations for disaster response and/or recovery or Continuity of Operations (COOP) activation. Supports and mission and vision of the hospital.

Performs other duties as assigned. Other duties as assigned include but are not limited to actively participating and/or serving in a supporting role to meet the agency’s obligations for disaster response and/or recovery or Continuity of Operations (COOP) activation. Such participation may require an alternate shift pattern assignment and/or location.

Requirements

• Knowledgeable of issues related to patient safety
• Skills in completing Root Cause Analysis, Management Initiated Reviews, and Proactive Risk Assessments.
• Skills in using performance improvement and quality monitoring processes.
• Ability to complete clinical audits and reports and maintain records.
• Ability to devise solutions to problems.
• Ability to communicate effectively.
• Skill using Microsoft Outlook, Word, and Excel.
• Knowledge of HIPAA, CMS, Joint Commission, Texas Administrative Code, and survey readiness techniques.
• Ability to interpret standards and apply appropriately.
• Knowledge of electronic medical records.
• Ability to gather, assemble, correlate, and analyze facts to prepare reports.
• Ability to write policy, identify need for policy update or new policy.
• Valid government identification.
• Experience reviewing clinical documentation.

Nice To Haves

• Three years of clinical work experience in nursing, social work, psychology, or related field preferred.

Responsibilities

• Attends work on a regular basis and may be asked to work a specific shift schedule or, at times, even a rotating schedule, extended shift and/or overtime in accordance with agency leave policy and performs other duties as assigned.
• Oversees assigned indicators including monitoring, data collection, analysis, presentation, and hospital wide reporting of the same through the hospitals committee structure.
• Serves as a member, facilitator, or consultant on assigned hospital standing committees including Pharmacy and Therapeutics, Environment of Care, Performance Improvement, Risk Management, and Medical Executive.
• Facilitates special projects as assigned by hospital leadership.
• Works closely with hospital leadership and committees in evaluating and improving the clinical safety program at the hospital. Coordinates and oversees activities of and participates in the development and implementation of the hospital Clinical Safety Program including proactive assessments of patient safety concerns and determination of standards compliance, development and oversight of the collection, analysis, and reporting of data related to clinical safety, and participates in various hospital committees, as assigned.
• Serves as the primary consultant and active participant on Root Cause Analysis, Management Initiated Reviews, and Proactive Risk Assessments. Monitors plan of correction for Management Initiated Reviews and Root Cause Analysis and maintain tracking mechanisms to track trends and to ensure all are completed in a timely manner. Makes recommendations related to trends in data.
• Participates in the development of staff education related to patient safety concerns.
• Supports the hospital’s overall Joint Commission and CMS survey and continuous readiness activities.
• Ensures the facility conforms to the conditions of participation for the facility as a Centers for Medicaid and Medicare Services (CMS) provider serving persons with mental health diagnoses, the Joint Commission (TJC) standards, and all other relevant state and federal laws, rules, and regulations. Interprets regulations/standards, develops, and disseminates policy, performs advanced consultative services to program staff, and coordinates a comprehensive system of implementing and reporting on quality enhancement efforts.
• Performs other duties as assigned. Other duties as assigned include but are not limited to actively participating and/or serving in a supporting role to meet the agency’s obligations for disaster response and/or recovery or Continuity of Operations (COOP) activation. Such participation may require an alternate shift pattern assignment and/or location.

Benefits

• Our comprehensive benefits package includes 100% paid employee health insurance for full-time eligible employees, a defined benefit pension plan, generous time off benefits, numerous opportunities for career advancement and more.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed