Director of Compliance & Quality Assurance with Remote Option
Do you believe everyone is entitled to quality healthcare? Do
you desire to serve the underserved in our community?
Southwest Care Center (SCC) is a non-profit healthcare
organization who has been providing exceptional healthcare to
people within our community for over 25 years. We provide services,
including medical, behavioral healthcare, and community outreach,
with health centers located in Santa Fe, Albuquerque, Farmington,
and Roswell, NM. Southwest Care Center is an FQHC-LAL.
SCC has an opportunity for a Director of Compliance & Quality
Assurance to join our team. The position is located in Santa Fe, NM
with remote option available. Great quality of life/work
opportunity with Monday through Friday schedule.
Must have a strong desire to make a difference in the community.
Must embrace a team-oriented approach and be comfortable working
with and leading a team of clinical and administrative
Southwest Care Center offers a full benefits package including
medical, dental, vision, life, long term and short-term disability
and a 401k retirement fund. Essential Duties: COMPLIANCE: Works
collaboratively with functional area directors and executives to
develop a compliance plan aimed at prevention, detection,
education, and resolution of variances. Evaluates plans, policies
and procedures as needed for gaps as they relate to emerging
regulations or evolving company needs.
Develops an annual workplan that is reflective of identified and
prioritized risks of non-compliance. This plan is submitted
to the CEO for approval by the Governing Board Compliance
Committee. Provides quarterly updates and reporting dashboards as
Develops and conducts compliance training (no less than
Maintains a compliance hotline in accordance with SCC’s Code of
Conduct Policy and leads investigations into reported matter as
appropriate. Documents all reported concerns, and includes
disposition of concerns in quarterly reports.
Provides expert advice on the development, communication and
implementation of key objectives to achieve PCMH certification.
Working collaboratively with clinical stakeholders and the
Quality personnel to develop and maintain a quality program
including scorecards, metrics and other plans to meet and exceed
Collaboratively participates in initiatives to develop clinical
best practices and drives accountability for consistent execution
across the organization.
Participates in community and industry activities in an effort
to enhance community recognition of SCC and the medical group, and
to obtain cooperation and support of the community on issues that
impact SCC and the health of the population we serve. Positively
represents SCC and the medical group in the community.
Participates in staff meetings and attends other meetings and
seminars as requested.
QUALITY ASSURANCE: Organizationally responsible to the overall
accountability and responsibility for planning, designing,
integrating, implementing, modifying, managing and evaluating the
performance improvement program, which is intended to review
services to measure and improve the quality of patient care and the
appropriateness, effectiveness, and timeliness of services
Incumbent must have the ability to analyze health care data
obtained from a variety of sources, including patient care,
clinical trials, financial, and demographic data, from
conceptualization through presentation of the data; including but
not limited to merging data sets, analyzing data and producing
meaningful performance improvement reports.
Provides leadership in improving patient care, maintaining
standards of care, and directing and teaching personnel in a
variety of settings by developing and facilitating the
implementation of programs in the health care system which impact
patient care at each site.
Responsible for coordinating all continued performance
improvement and compliance activities for associated external and
accreditation reviews. The incumbent assures year-to-year
compliance with standards of outside agencies and regulatory
Researches information by identifying, locating and extracting
relevant data and information from varied sources in order to
obtain sufficient, valid and reliable data for analysis and
Analyzes information using qualitative and/or quantitative
analytical methods in order to understand and draw fact-based
conclusions, often from large amounts of information; identifies
issues and problems requiring additional research and study and
takes appropriate action to ensure sound study results.
Develops, designs and implements clinical quality improvement
performance dashboards for SCC clinics to improve patient care
while focusing on clinical outcomes and population health. Develops
and maintains a clinical data base.
Interacts with a variety of individuals when participating in
meetings, making presentations, providing advice and/or
recommendations in order to communicate information, share ideas,
present recommended solutions, gain agreement and coordinate
investigates any possible adverse events, as defined by
Southwest Care Center, state and/or regulatory agencies.
Participates in the planning, coordination and presentation of
specific training and educational programs as appropriate to
quality improvement needs of SCC.
Participates in conferences, workshops, symposiums and lectures
related to quality management.
Develops policies and procedures to support the quality
Develops, implements and oversees (1) satisfaction surveys, (2)
quality improvement plans and goals, (3) quality improvement
projects. Provides results and recommendations to Leadership
Participates in clinical and programmatic evaluation
Participates in third party reporting requirements related to
quality improvement and data.
Conducts an annual evaluation of the quality improvement program
and provides results and recommendations to the Leadership
Performs other duties as assigned. Additional duties may include
direct support and reporting to other regulatory agencies, as well
as other compliance requirements, all to be performed in a timely
and accurate manner.
Minimum Qualifications: Experience: Minimum two years compliance
and quality experience in a healthcare setting. A minimum of 7
years’ healthcare leadership and/or medical group administration
experience. Leadership experience in a Patient Centered Medical
Home and or Federally Qualified Health Center required.
Education: Bachelor’s degree in business, health administration,
public health, nursing, social work or related field.
Mandatory Knowledge, Skills, Abilities and Other Qualifications:
Knowledge of HIPAA guidelines, Medicare/Medicaid regulations and
other federal, state and programmatic regulations typically
applicable to grant funded, community healthcare organizations.
Budgeting, planning and analysis.
Proven ability to motivate and lead effective cross-functional
teams to achieve desired outcomes.
Project Management experience implementing large-scale strategic
initiatives which align with business goals across multiple
departments/sites with demonstrated success.
Excellent written and verbal communication skills and the
ability to handle sensitive and confidential situations and
Solid analytical, critical thinking and problem-solving skills.
Demonstrated effectiveness in identifying operational issues and
recommending and implementing solutions to resolve and effectively
communicating both in verbal and written formats.
Solid analytical, critical thinking and problem-solving
Ability to maintain and build trust; protect and preserve
confidential information along with high attention to detail.
Ability to prioritize effectively and meet strict deadlines
while managing multiple, competing tasks in a fast-paced
Strong team player able to form functional relationships with
peers and superiors.
Ability to perform other duties as assigned.
Knowledge of Microsoft Office Suite; (Word, Excel, Outlook);
internet browser/search engine; and electronic database employee
Basic operation of a workstation (turn off/on, knowledge of
basic functions and components).
Use/storage/maintenance of multiple usernames and passwords.
Use of Windows Explorer (electronic file-handling).
Regular and predictable punctuality and attendance are a
requirement of this position.
Performs other duties as required and assigned.
Preferred Qualifications: MSN, MBA, MHA, MSW or similar advanced
Experience with AAAHC and/or NCQA accreditation.
Experience in a setting with fully integrated behavioral health
and enabling/outreach programs.
To Thrive at Southwest Care Center You Must: Be committed to
SCC's mission, vision, and values and demonstrate them to patients,
colleagues, and the public in everyday performance and
Uphold all principles of confidentiality and patient care to the
Adhere to all professional and ethical behavior standards of the
Interact in an honest, trustworthy and respectful manner with
patients, employees, visitors and vendors.
Participate in departmental staff meetings, quality management
activities and educational programs.
Comply with Southwest CARE Center policies and procedures.
Maintain a current insurable driver’s license.
Southwest Care Center is an equal opportunity employer. We offer
equal employment opportunities to employees and applicants without
regard to race, color, religion, sex, age, national origin,
disability status, protected veteran status, sexual orientation,
gender identity, or any other characteristic protected by federal
or state law. Job Details: Location: NM Santa Fe - San Mateo Worker
Type: EmployeeRegular Scheduled Weekly Hours: 40