Transplant Quality and Regulatory Administrator - Transplant Surgery Clinic
Job Description
GENERAL SUMMARY:
The Senior Transplant Quality Manager will be reporting to the Director of Surgery and Transplant Services. The primary responsibilities are to support the quality and process improvement efforts and initiatives, collect and organize the data and analyze data to assist the QAPI team with external and internal quality measures. The Senior Transplant Quality Manager performs work related to the QA data collection/analysis, project managing and performance improvement (QAPI) of the Bone Marrow and Solid Organ Transplant program, while working independently and/or in collaboration with the senior leaders, transplant management, and physician directors.
The Senior Transplant Quality Manager identifies potential problems in the continuity of care process as a result of data collection, data aggregation, and analysis of sensitive and proprietary information. Under the guidance of the Transplant Quality team, monitors compliance with Tufts’ global policies, CMS Transplant Quality Assessment and Performance Improvement Program guidelines, Joint Commission’s guidelines, FACT guidelines and UNOS regulations.
The Senior Transplant Quality Manager has an in-depth knowledge of the regulations governing transplant programs including the VAD program and will be responsible for maintaining current understanding of data abstraction specifications required for data submission to Joint Commissions, CMS, UNOS, and INTERMACS. The Senior Transplant Quality Manager will ensure that external and internal reporting deadlines for data abstraction, submission, and reporting are met as per established basis. The Senior Transplant Quality Manager must have experience with the application of all the rapidly evolving regulations governing transplant centers, including the very unique Medicare cost reporting requirements for organ acquisition and ITL which includes assessment of hospital and PO financial statements in conjunction with the reimbursement team. The Transplant Quality Manager will also be responsible for process improvement and project managing improvement efforts across financial and operational arenas with a focus on evidence-based methods of problem-solving.
The Transplant Quality Manager will be responsible for supervising TIEDI data entry staff and processes and policies associated with data entry into all transplant and VAD related databases including UNOS, CIBMTR and INTERMACS.
II. PRINCIPAL DUTIES AND ESSENTIAL FUNCTIONS:
Regular monitoring and tracking of the departmentpolicies and procedures (P&P) in order to ensure regulatory compliance with UNOS, FACT, Joint Commission and CMS.
Oversight of maintaining and storage of regulatory documents and outcomes
Responsible for overseeing the creation and maintenance of all transplant procedures; ensure they comply with transplant regulatory requirements
Responsible for overseeing continuous audits for regulatory compliance.
Responsible for identifying corrective action plans for deviations and adverse events, as deemed necessary.
Quality Activities and report to the regulatory committee and QAPI/Hospital Quality and Medical Board:
Prepares and tracks all regulatory audits and dashboards for reporting at committee meetings
Responsible for overseeing the maintenance of the Heart and Kidney transplant summary and dashboard (via XYN Management) to track volume and quality measures – this is the primary source of all transplant data as needed by internal and external users. Responsible for overseeing the maintenance for the bone marrow transplant data dashboard.
Collaborates with Quality Improvement and Regulatory Affairs to monitor clinical outcomes and perform audits for the Transplant Quality Improvement Committee and any corrective action plans as requested by internal and external agencies.
Survey Readiness preparation including CMS accreditation, FACT accreditation, VAD certification as well as coordination of routine UNOS site surveys. Lead audit preparation activities in conjunction with the Quality and Patient Safety Department, coordinates all activity during on-site audits and coordinate the development and monitoring of post-audit corrective action plans.
The incumbent will be responsible for management of staff related to data entry into transplant regulatory Systems including UNOS, CIBMTR and INTERMACS. This includes developing data entry policies as well as oversight of the process.
Responsible for communication with regulatory bodies – including response to requests for allocation analyses, communication with surveyors, requests for data and communication through the patient safety portal. Also responsible for the coordination of the annual OPTUM and UNOS Transplant RFIs; gather and analyze data to complete surveys in a timely manner; work collaboratively with faculty to ensure optimal representation of the transplant program to payers.
Coordinate QAPI projects
Documents problem statements, owners, actions and measurements
Tracks and monitors status per program
Tracks and monitors CG and HCAHPS
Lead Performance Improvement projects with an emphasis on quality improvement, increased automation, and utilization of our electronic medical record.
Other duties as assigned within the scope of the quality and process improvement role.
Assist with completion of Request for Information (RFIs) for insurance providers.
Qualifications
GENERAL SUMMARY:
The Senior Transplant Quality Manager will be reporting to the Executive Director of Surgery and Transplant Services. The primary responsibilities are to support the quality and process improvement efforts and initiatives, collect and organize the data and analyze data to assist the QAPI team with external and internal quality measures. The Senior Transplant Quality Manager performs work related to the QA data collection/analysis, project managing and performance improvement (QAPI) of the Bone Marrow and Solid Organ Transplant program, while working independently and/or in collaboration with the senior leaders, transplant management, and physician directors.
The Senior Transplant Quality Manager identifies potential problems in the continuity of care process as a result of data collection, data aggregation, and analysis of sensitive and proprietary information. Under the guidance of the Transplant Quality team, monitors compliance with Tufts’ global policies, CMS Transplant Quality Assessment and Performance Improvement Program guidelines, Joint Commission’s guidelines, FACT guidelines and UNOS regulations.
The Senior Transplant Quality Manager has an in-depth knowledge of the regulations governing transplant programs including the VAD program and will be responsible for maintaining current understanding of data abstraction specifications required for data submission to Joint Commissions, CMS, UNOS, and INTERMACS. The Senior Transplant Quality Manager will ensure that external and internal reporting deadlines for data abstraction, submission, and reporting are met as per established basis. The Senior Transplant Quality Manager must have experience with the application of all the rapidly evolving regulations governing transplant centers, including the very unique Medicare cost reporting requirements for organ acquisition and ITL which includes assessment of hospital and PO financial statements in conjunction with the reimbursement team. The Transplant Quality Manager will also be responsible for process improvement and project managing improvement efforts across financial and operational arenas with a focus on evidence-based methods of problem-solving.
The Transplant Quality Manager will be responsible for supervising TIEDI data entry staff and processes and policies associated with data entry into all transplant and VAD related databases including UNOS, CIBMTR and INTERMACS.
II. PRINCIPAL DUTIES AND ESSENTIAL FUNCTIONS:
Regular monitoring and tracking of the department policies and procedures (P&P) in order to ensure regulatory compliance with UNOS, FACT, Joint Commission and CMS.
Oversight of maintaining and storage of regulatory documents and outcomes
Responsible for overseeing the creation and maintenance of all transplant procedures; ensure they comply with transplant regulatory requirements
Responsible for overseeing continuous audits for regulatory compliance.
Responsible for identifying corrective action plans for deviations and adverse events, as deemed necessary.
Quality Activities and report to the regulatory committee and QAPI/Hospital Quality and Medical Board:
Prepares and tracks all regulatory audits and dashboards for reporting at committee meetings
Responsible for overseeing the maintenance of the Heart and Kidney transplant summary and dashboard (via XYN Management) to track volume and quality measures – this is the primary source of all transplant data as needed by internal and external users. Responsible for overseeing the maintenance for the bone marrow transplant data dashboard.
Collaborates with Quality Improvement and Regulatory Affairs to monitor clinical outcomes and perform audits for the Transplant Quality Improvement Committee and any corrective action plans as requested by internal and external agencies.
Survey Readiness preparation including CMS accreditation, FACT accreditation, VAD certification as well as coordination of routine UNOS site surveys. Lead audit preparation activities in conjunction with the Quality and Patient Safety Department, coordinates all activity during on-site audits and coordinate the development and monitoring of post-audit corrective action plans.
The incumbent will be responsible for management of staff related to data entry into transplant regulatory Systems including UNOS, CIBMTR and INTERMACS. This includes developing data entry policies as well as oversight of the process.
Responsible for communication with regulatory bodies – including response to requests for allocation analyses, communication with surveyors, requests for data and communication through the patient safety portal. Also responsible for the coordination of the annual OPTUM and UNOS Transplant RFIs; gather and analyze data to complete surveys in a timely manner; work collaboratively with faculty to ensure optimal representation of the transplant program to payers.
Coordinate QAPI projects
Documents problem statements, owners, actions and measurements
Tracks and monitors status per program
Tracks and monitors CG and HCAHPS
Lead Performance Improvement projects with an emphasis on quality improvement, increased automation, and utilization of our electronic medical record.
Other duties as assigned within the scope of the quality and process improvement role.
Assist with completion of Request for Information (RFIs) for insurance providers.
Additional Information
AMERICANS WITH DISABILITIES STATEMENT:
Must be able to perform all essential functions of this position with reasonable accommodation if disabled.
The above statements are intended to describe the general nature and level of work being performed. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of personnel so classified. New England Medical Center reserves the right to modify position duties at any time, to reflect process improvements and business necessity.
All your information will be kept confidential according to EEO guidelines.
AMERICANS WITH DISABILITIES STATEMENT:
Must be able to perform all essential functions of this position with reasonable accommodation if disabled.
The above statements are intended to describe the general nature and level of work being performed. They are not intended to be construed, as an exhaustive list of all responsibilities, duties and skills required of personnel so classified. Tufts Medical Center reserves the right to modify position duties at any time, to reflect process improvements and business necessity.
COVID-19 POLICY:
Please note that effective October 1, 2021, as a condition of employment at Tufts Medical Center, all employees and new hires must have received their complete dose of the COVID-19 vaccine, unless they have been granted an exemption.