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Performance Improvement & Compliance Administrator

Company: Wellpath
Location: Indiantown
Posted on: October 8, 2021

Job Description:

Here at Wellpath, everything that we do is about taking care of people - our patients, our staff and our partners. We are committed to making a difference by providing hope and healing to vulnerable patients in challenging clinical environments. Our talented, compassionate team thrives in an autonomous environment, is empowered and supported by education, training and the resources to practice healthcare the way it is meant to be and strives to "Always Do The Right Thing!"


Our Performance Improvement and Compliance Administrator directs hospital-wide performance improvement activities. Designs and implements programs, policies and practices to ensure that all departments are in compliance with DHEC, NCCHC, and TJC accreditation standards, HIPAA regulations and all applicable state, federal and local statutes pertaining to hospital licensing and regulation, as applicable. Works directly with facility leadership to ensure compliance with the contract between the hospital and contracting agencies for the management of the hospital. In addition, this position ensures compliance to all organizational, contractual, state and federal rules and regulations.



  • Bachelor degree in human services or health care field.
  • Master degree is preferred

  • Five (5) years management demonstrated experience in compliance or performance improvement administration
  • Previous experience in a hospital or corrections environment preferred (A combination of educational and work experience may be taken into consideration based on management's discretion.)
  • Knowledge of TJC or comparable agency accreditation requirements

  • None required

  1. Designs and implements programs, policies, and practices to insure that all departments are in compliance with The Joint Commission (TJC) accreditation standards, HIPAA regulations, and all applicable federal, state and local statutes pertaining to hospital licensing and regulation.
  2. Tracks laws and regulations that might affect the facilities requirements.
  3. Works directly with the leadership to ensure compliance with the contract between hospital and the state's DCF for the management of the facility.
  4. Coordinates the preparation and submission of responses and corrective action plans. Follows-up (as applicable) with DCF representative, TJC, American Health Care Association (AHCA), Center for Medicare and Medicaid Services (CMS) or any other accreditation or regulatory body.
  5. Provides direct supervision to the Medical Records Coordinator.
  6. May be required to monitor medical records compliance and completes Steton Audit reports, if applicable.
  7. Directs initiatives to reduce medical and healthcare errors, serious injuries and other adverse patient outcomes. Facilitate continuous process improvement as a component of each event.
  8. Monitors indicator reports to track trends and help ensure that significant trends are being reported to executive management in a concise format and are being addressed in a timely manner.
  9. Provides a resource for the Utilization Management Plan, peer review process, and related activities.
  10. Chairs and oversees the facilities Performance Improvement Program. Provides technical assistance to ensure effective use of the team approach to performance improvement. Provides Quality Management training to all staff and trains process teams on how to run and facilitate teams.
  11. Manages processes for developing, revising, and disseminating policies, procedures and protocols for the facility.
  12. Develops or revises operating procedures for management. Maintains current records of the status of operating procedures. Informs and trains staff on new and revised procedures. Maintains an electronic procedure manual.
  13. Establishes the facilitiess compliance program. Chairs the compliance committee for the facility. Establishes and oversees internal reporting processes and develop procedures to encourage managers and employees to report suspected violations. Coordinates development and implementation of auditing processes to ensure compliance. Conducts investigations of alleged non-compliance issues. Provides orientation to management and staff on the compliance program.
  14. Serves as primary liaison on contract, licensing, and certification related matters. Prepares and responds to inquiries related to compliance. Prepares regular reports to management on contract, licensing, or certification matters.
  15. Directs initiatives to reduce medical/healthcare errors, serious injuries and other adverse patient outcomes. Facilitate continuous process improvement as a component of each event.
  16. Ensures that departments, committees, PI teams and hospital leadership utilize appropriate data collection analysis methods and tools to measure processes and outcomes, assess performance, identify opportunities for improvement and follow-up with identified actions.
  17. Provides training to staff on PI methods, tools, team approaches, root cause analysis, and project presentations.
  18. Must be able to apply principles of critical thinking to a variety of practical and emergent situations and accurately follow standardized procedures that may call for deviations.
  19. Must be able to apply sound judgment beyond a specific set of instructions and apply knowledge to different factual situations.
  20. Must be alert at all times; pay close attention to details.
  21. Must be able to work under stress on a regular or continuous basis.
  22. Perform other duties as assigned.

Wellpath is an EOE/Minorities/Females/Vet/Disability Employer

Keywords: Wellpath, Palm Beach , Performance Improvement & Compliance Administrator, Other , Indiantown, Florida

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