Quality & Regulatory Coordinator

Quality & Regulatory Coordinator

Under the general supervision of the Director of Risk & Compliance, performs liaison services to patients and families of First Choice Community Healthcare regarding navigation for breast and cervical cancer.

Breast and Cervical Cancer Duties:

• Process all well women exams by completing the Department of Health Navigation forms for clients failing to complete screening appointments; and tracks by using a tickler system for appointments and billing purposes;
• Update First Choice Community Healthcare clinics on navigation and BCC contract updates to comply with the protocol and well functioning of the program at FCCH;
• Works in cooperation with the BCC contacts at FCCH sites.
• Act as a liaison between Department of Health BCC program and other entities related to the BCC program;
• Obtains required information by interviewing applicants, family members, and others; completing the navigation forms; confirming information for accuracy; obtains assistance for applicants/clients by referring them to the appropriate contacts for community programs and services;
• Facilitate the appointment making process for all women who have failed to complete well women exam, as appointed;
• Use the Patient Navigation form to assess and document the need for patient navigation services;
• Provide and participate in patient education activities with assistance from the BCC program; activities may include: evidence based screening guidelines; risk factor information; and recommendations for positive behavior changes;
• Ensure staff participation in at least one BCC program orientation session per year;
• Work with the NM Department of Health BCC Health Educators to implement clinic-based patient activities for clients who may have barriers to care and to support breast and cervical cancer screening services for low-income women who otherwise would not complete the screening process;
• Coordination of mammovan (Department of Health)
• Assist with or provide training and meetings regarding issues pertaining to the BCC and Navigation programs; Provides documentation of navigation forms and billing invoices to Department of Health using the program eligibility criteria provided by Department of Health;
• Evaluates success of program with the Director of Risk & Compliance;
• Completes CEU's as required by NMDOH;
• Attend quarterly partnership meetings;

Quality & Regulatory Duties:

Compliance Tracking & Reporting:

• Monitor and track fire drills, handwashing compliance, and general drill;
• Maintain and audit all survey findings;
• Track and file occurrence reports and FTCA compliance documentation;
• Monitor flu vaccine administration across all sites;
• Track DOT training completion for relevant personnel;
• Report and track communicable disease counts for all facilities;
• Maintain records for backflow and sprinkler inspections (Western States);
• Monitor and track fire alarm and sprinkler system inspections and security access logs;

Performance Improvement (PI):

• Coordinate bi-monthly PI visits and create scheduling with PI team members;
• Enter PI data into appropriate tracking systems;
• Distribute and track Trilogy (Biohazard) reports; ensure binders are up to date;
• Serve as the primary liaison for Trilogy-related communication and reporting;

Administrative Support & Coordination:

• Serve as a resource for employee questions and support needs;
• Order and distribute site supplies, including OC Lights and bulk clinical materials (e.g. N-95 masks, gowns, IV supplies, Tegaderm, basins);
• Assist with lab supply deliveries as needed;

Vendor & Equipment Coordination:

• Act as the main point of contact for the optical vendor;
• Coordinate microscope service and maintenance with vendor;
• Coordinate western states visits for fire safety compliance;

HIPAA Compliance:

• File breach reports and manage documentation;
• Prepare and send HIPAA notification letters when necessary;

Regulatory Preparedness & Miscellaneous Duties:

• Support emergency preparedness training and planning;
• Assist in developing safety meeting agendas and record meeting minutes;
• Coordinate tool sharpening send-outs and returns as needed;
• Facilitate Regulatory Quality and Safety meetings;
• Supervise, train, direct and oversee the Bio Med Technician;
• Other duties as assigned

Minimum Education and Experience:

• Bachelor's degree (BA); or one to two years related experience and/or training; or equivalent combination of education and experience;
• Previous successful experience in a community service program or outreach preferred;
• Bi-lingual in English and Spanish preferred;

Knowledge, Skills, and Abilities Required:

• Ability to work as a team member within a clinical environment;
• Records maintenance skills;
• Excellent verbal and written communication skills;
• Customer service skills;
• Reliable transportation needed as travel in the Albuquerque area and adjacent counties is required;
• Must be willing to work out in the community;
• Must be able to work autonomously;
• Ability to develop and maintain filing systems;
• Ability to complete routine paperwork;
• Ability to maintain confidentiality of records and information;
• Skill in the use of operating basic office equipment;
• Ability to follow routine verbal or written instructions;
• Ability to maintain quality, safety, and/or infection control standards;
• Ability to maintain patient confidentiality;
• Knowledge and familiar with compliance program, corporate fully and comply with laws and regulations;

Age of Patients Served:

Adult and geriatric

Physical Characteristics/Working Conditions:

A person in this position has sufficient time to complete most tasks although under pressure depending on patient and organization demands. There are frequent opportunities to relax from any physical exertion or to change position in work activities.

• Physical Effort and Dexterity : Good dexterity to operate personal computer, and files. Moderate physical activity. Requires handling of average-weight objects up to 25 pounds or standing and/or walking for more than four (4) hours per day.
• Machines, Tools, Equipment required to be operated : Capable of using office machines and personal computers for word processing, data entry and retrieval.
• Visual Acuity, Hearing, and Speaking : Must be able to read computer monitor output. Must be able to communicate clearly and accurately for work and safety compliance.
• Environment/Working Conditions : Work is mostly inside a clinic in a controlled environment. Normal clinic safety precautions and practices are required. Position may require travel throughout the Albuquerque metropolitan area and adjacent counties. Work regularly scheduled Monday-Friday, although weekends may be required to meet deadlines.

This description lists the major duties and requirements of the job and is not all-inclusive. Applicants may be expected to perform job-related duties other than those contained in this document and may be required to have specific job-related knowledge and skills.