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Job Summary:

The BWH Dialysis Compliance Specialist works collaboratively with members of the BWH Dialysis team, reporting directly to the Administrative Director of Dialysis & Infusion. The Dialysis Compliance Specialist will also partner with the Clinical Compliance Department to ensure all Centers for Medicare and Medicaid Services (CMS), Department of Public Health (DPH) and the Joint Commission (TJC) dialysis regulatory requirements are met.
The Dialysis Compliance Specialist supports initiatives that strengthen the Dialysis Quality Assurance and Process Improvement (QAPI) activities, governance, and regulatory compliance. The position also has responsibility for auditing, reviewing and assessing/trending data related to regulatory compliance and QAPI, as well as aiding with implementation of corrective action plans and development of policies and procedures in response to regulatory initiatives within these programs.

The Dialysis Compliance Specialist will assist the Administrative Director with coordinating and monitoring ongoing compliance-related education efforts within the Dialysis department. They serve as the BWH Dialysis liaison for all BWH Readiness initiatives.

The Dialysis Compliance Specialist provides operational support for the Dialysis department including ensuring compliance with all CMS ESRD regulatory requirements, monitoring patient throughput from admission to discharge, and aiding in outpatient dialysis placement. Additionally, the Dialysis Compliance Specialist is responsible for a variety of administrative, data management, materials management and equipment, quality control and data collection and reporting.

Qualifications:

PRINCIPAL DUTIES AND RESPONSIBILITIES:

BWH Dialysis: Regulatory External Agencies

• Works in collaboration with the Administrative Director, Nurse Manager, Medical Director, and Clinical Compliance as the BWH Dialysis Liaison as appropriate to external regulatory agencies (CMS, DPH, TJC) to implement and maintain compliance with regulations and to serve as a Quality Program Leader resource to dialysis staff.
• Serves as the BWH Dialysis Liaison to external reporting agencies (CMS Consolidation Renal Operations in a Web-Enabled network (EQRS), Centers for Disease Control and Prevention National Healthcare Safety Network (NHSN) and provides interpretive and operational guidance to staff as appropriate by utilizing BWH Clinical Documentation to review regulatory data reporting, ensure accuracy, and guarantee timely submissions to meet quality of care standards.

BWH Dialysis: QAPI/Governance Program

• Facilitates the BWH Dialysis Quality Assurance Process Improvement (QAPI) program by liaising between BWH Dialysis Governance, BWH Risk Management/Compliance, BWH Readiness/Leadership, BWH Infection Control, and BWH Biomedical Engineering.
• Works in collaboration with the Administrative Director, Nurse Manager and Medical Director to determine necessary points of discussion for monthly and quarterly Dialysis QAPI/Governance Committee Meetings (e.g. regulatory changes, departmental auditing, results of data analysis, and corrective action plans).
• Utilizes performance improvement tools and interventions to develop and operationalize projects to identify, gather and trend data to support regulatory Dialysis QAPI initiatives. He/she will analyze data collected against benchmarks to identify trends that may or may not align with projected/desired outcomes.
• Oversees, develops, implements and maintains Dialysis QAPI special projects as determined by the Governance Board.
• Develops and maintains Dialysis scorecards and dashboards.
• Supports the department with the implementation of new guidelines, protocols and processes related to regulatory compliance and quality assurance program activities and initiatives while ensuring the most current data analysis trends and action plans are appropriately disseminated to staff.

BWH Policies & Procedures: Document Control

• Works to develop document control and workflow management processes to streamline policy access and dissemination (e.g. governmental review, revising, approval, and archiving) across the Dialysis unit.
• Partners with dialysis staff, and subject-matter experts to develop and amend policies and procedures in accordance with regulatory changes, best practices, and quality of care standards.
• Ensures that all program policies, management guidelines and job descriptions are reviewed as required by the appropriate personnel and maintains current documents in preparation for regulatory surveys.
• Updates and maintains all Dialysis QAPI records for CMS, DPH, and TJC surveys.
• Ensures operational documents (e.g. machine disinfection logs, code check logs, etc.) are completed and maintained appropriately.

Supervisory Responsibilities:

• Oversees and/or coordinates department orientation and competencies/trainings.
• Supports Staff as a resource in information systems (ex. Epic needs).

Additional Operational Responsibilities:

• Serves as the Dialysis representative at all BWH Readiness meetings and tracers while partnering with the Governance team in developing and facilitating a readiness program for regulatory surveys.
• Provides Operational Support for the Dialysis Department including monitoring of treatment volume, patient throughput, regulatory compliance and education initiatives.
• Coordinates all dialysis meetings including sending out reminders, creating and disseminating agenda, prepares meeting minutes and attendance and ensures follow-up on identified next steps.
• In collaboration with Social Work, Nurse Manager, Administrative Director, and medical team monitors dialysis outpatient placement process to ensure timely discharge to outpatient dialysis facilities.
• Acts as liaison between dialysis unit and biomed department, partnering with the Dialysis Chemical Engineer to ensure compliance with machine disinfection and maintenance schedule.
• Collaborates with Patient Care team in obtaining information/planning on new products/technology; facilitates the introduction of new equipment/supplies.
• Performs other duties, as assigned.

QUALIFICATIONS:

Bachelor’s Degree required. Master’s degree preferred. Compliance Certification Board strongly preferred (CHC, CHPC, CHRC, or CHC-F) Experience (2+ years) in large, complex clinical and/or academic medical setting preferred. Experience in outpatient dialysis setting strongly preferred. Experience with quality/process improvement strongly preferred. Experience working with external regulatory agencies (i.e. CMS, DPH, TJC, etc.) strongly preferred. Knowledge of and competence with word processing, Excel and PowerPoint Required

SKILLS/ABILITIES/COMPETENCIES REQUIRED:

• Self-directed, able to work independently, and demonstrates high level of motivation
• Strong interpersonal skills; able to communicate effectively, both written and verbal
• Superior organizational skills and ability to prioritize and multitask appropriately
• Demonstrated ability to complete work through collaborative efforts with individuals representing various specialty areas
• Ability to analyze and present data in a clear, concise and accurate manner
• Ability to complete work and meet deadlines
• High level of professionalism
• Ability to work in fast-paced environment
• Strong computer skills (Word, Excel, PowerPoint) with ability to utilize spreadsheets and graphic programs to produce bar graphs and charts
• Available for early or late meetings to accommodate clinician schedules

Additional Job Details (if applicable)

Physical Requirements

• Standing Occasionally (3-33%)
• Walking Occasionally (3-33%)
• Sitting Constantly (67-100%)
• Lifting Occasionally (3-33%) 20lbs - 35lbs
• Carrying Occasionally (3-33%) 20lbs - 35lbs
• Pushing Rarely (Less than 2%)
• Pulling Rarely (Less than 2%)
• Climbing Rarely (Less than 2%)
• Balancing Occasionally (3-33%)
• Stooping Occasionally (3-33%)
• Kneeling Rarely (Less than 2%)
• Crouching Rarely (Less than 2%)
• Crawling Rarely (Less than 2%)
• Reaching Occasionally (3-33%)
• Gross Manipulation (Handling) Constantly (67-100%)
• Fine Manipulation (Fingering) Frequently (34-66%)
• Feeling Constantly (67-100%)
• Foot Use Rarely (Less than 2%)
• Vision
• Far Constantly (67-100%)
• Vision
• Near Constantly (67-100%)
• Talking Constantly (67-100%)
• Hearing Constantly (67-100%)

Remote Type

Hybrid

Work Location

15 Francis Street

Scheduled Weekly Hours:

40

Employee Type

Regular

Work Shift

Day (United States of America)

Pay Range

$79,560.00 - $115,720.80/Annual

Grade

7

At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive, and any offer extended will take into account your skills, relevant experience if applicable, education, certifications and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass all elements contributing to your total compensation package. In addition to competitive base pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth. We invite you to apply, and our Talent Acquisition team will provide an overview of your potential compensation and benefits package.

EEO Statement:

2200 The Brigham and Women's Hospital, Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veteran’s Readjustment Act of 1974, and Title I of the Americans with Disabilities Act of 1990, applicants who require accommodation in the job application process may contact Human Resources at (857)-282-7642.

Mass General Brigham Competency Framework

At Mass General Brigham, our competency framework defines what effective leadership “looks like” by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline.