Regulatory Compliance Program Manager

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PURPOSE AND SCOPE: Supports FMCNA’s mission, vision, core values and customer service philosophy.  Adheres to the FMCNA Compliance Program, including following all regulatory and FMS policy requirements. Coordinates regulatory and clinical audits and promotes utilization of continuous quality improvement (CQI) principles, methods and tools.  Responds to, investigates and initiates resolution of regulatory and compliance inquiries initiated by VP’s of Quality, RVPs, Clinical Services and Medical Office.  Collaborates with the Group RQMs, RDEs, RVPs, Directors Operations and Area Managers to ensure the continual improvement of clinical outcomes experience by FMCNA patients and to ensure compliance by company facilities to federal, state and local laws and regulations.  Serves as an UltraCare champion and role model.  DUTIES / ACTIVITIES: CUSTOMER SERVICE: Responsible for driving the FMS culture through values and customer service standards. Accountable for outstanding customer service to all external and internal customers. Develops and maintains effective relationships through effective and timely communication. Takes initiative and action to respond, resolve and follow up regarding customer service issues with all customers in a timely manner.PRINCIPAL RESPONSIBILITIES AND DUTIES Coordinates with Quality Education and Technical departments to provide educational activities as needed to achieve compliance with federal, state and local laws and regulations. Makes recommendations and provides guidance to operations when concentrated restoration and improvement efforts are required to re-establish compliance.    Identifies improvement opportunities to ensure compliance with company standards, policies and procedures, as well as federal, state and local regulations by conducting facility audits.  Conducts exit conferences with facility management staff to review survey findings and to make recommendations. Provides guidance to operations in the development, implementation and monitoring of a Plan of Correction (POC), improvement projects and activities.  May be asked to conduct focused audits by VPQ. Collaborates with facility, area and regional management staff to set and achieve improved regulatory and operational outcomes, identify risk areas and opportunities for improvement, and assist with root cause analysis, if indicated.  Monitors, trends and analyzes audit results, assists with root cause analyses and makes recommendations for process changes as identified.  Responds to facility and regional management to resolve inquires about clinical policies and procedures. Provides guidance, interpretation, and subject matter expertise when appropriate.         Conducts new facility audits to evaluate conformance to state licensure and CMS Conditions of Coverage to ensure safe operational condition and external survey readiness.        Educates and advances the use of the Quality Assessment and Improvement (QAI) Program tools and promotes utilization of CQI principles to ensure adherence to standard QAI activities, tracking and trending of required metrics, and identification and prioritization of performance improvement projects.  Recommends the use of appropriate tools and monitoring techniques to assist staff and QAI committee members in assessing their compliance. Utilizes spread techniques to diffuse and promote the use of effective demonstrated practices and collaboration between facilities and areas to share processes, procedures, and formulas for success.  Mentors and assists facilities in identifying effective practices applicable to their needs, in testing for desired results, and the adoption and implementation of these practices. Analyzes, manages and reports data as needed to identify improvement opportunities and measure the progress of improvement projects.  Prepares and disseminates reports on audit findings and corrective and preventive action recommendations to GVPQ, GVPR as well as operations management and corporate staff, and as needed.  Provides guidance and consultation to facilities and area management in their development and evaluation of plans of corrections in response to state and federal                      surveys.                                                                    Responds to emergent requests from VPQ to coordinate rapid response teams to assist with intervention and assistance with resolution of critical facility specific problems. Makes recommendations regarding root cause analysis, as well as solutions to identified problems, if appropriate.  Participates in QAI meetings as needed to evaluate effectiveness and provides guidance in improving processes. Fosters and maintains good working relationships with state survey agencies, CMS regional offices, ESRD Networks and other regulatory bodies that have jurisdiction over FMS facilities. Fosters and maintains good working relationships with the ESRD professional community to promote FMCNA as an industry leader Stays abreast of, and utilizes, current knowledge of FMS clinical and administrative policies and procedures, available internal resources, working knowledge of CMS Conditions of Coverage for ESRD facilities, knowledge of quality improvement concepts, principles and practices to perform tasks and duties. Other duties as assigned.