Overview
Quality Assurance Coordinator Jobs in Bryan, TX at Management & Training Corporation
LAC VIEUX DESERT BAND OF LAKE SUPERIOR CHIPPEWA INDIANS
LVDHC HUMAN RESOURCES
P.O. Box 9, N5241 Hwy 45 Watersmeet, MI. 49969
Phone: 906-358-4587 Fax: 906-358-4118
JOB DESCRIPTION
POSITION: Quality Assurance Risk Management Specialist
LOCATION: LVD Health Center, Watersmeet, MI
SUPERVISOR: Director of Facilities & Compliance
EMPLOYMENT: Full Time – Non-Exempt
SALARY/PAY RATE: Based on Experience & Qualifications
UPON HIRE:
PTO Upon Hire
Dental
Vision
Health Insurance
DESCRIPTION:
The purpose of the Lac Vieux Desert Health Center (LVDHC) Continuous Quality
Improvement and Assurance Program is to have an organized system in place with a
continual goal to strive for excellence. This position develops and maintains an active,
integrated, organized, ongoing, data-driven, and peer -based quality improvement
program that ensures quality care is provided, evaluated, and sustained improvements are
made.
RESPONSIBILITIES:
Quality Assurance/Quality Improvement:
Assure initiatives align with multiple quality guidelines, such as National Quality
Strategy, Clinical Practice Guidelines, HEDIS measures, Government
Performance and Results Act (GPRA), Standards of Care, Standards of Practice,
and other evidence-based recommendations
Leads the Continuous Quality Improvement, Quality Assurance Committee
Responsible for collecting, tracking, and trending data and benchmarking to
appropriate quality guidelines, while maintaining the confidentiality of patient
records
Develops and maintains a written quality improvement program with ongoing
data collection processes to measure quality and identify related problems or
concerns
Ensure quality improvement plans are in line with the organization’s missions and
goals
Remains current and knowledgeable of all quality mandates from regulatory and
accreditation bodies
Compares internal performance measures to external benchmarking and results
are incorporated into quality improvement activities
Coordinate with departmental managers in creating meaningful quality assurance
processes, monitoring success of corrective action plans, and appropriately
closing plans
Ensure compliance with federal, state and local healthcare quality and safety
standards and regulatory requirements
Ensures data analysis is documented to demonstrate that continuous quality
improvement is occurring
Assists directors and departmental leaders in defining performance indicators and
developing measurement tools to evaluate quality improvements
Facilitate communication and collaboration among departments to promote a
culture of continuous improvement
Provider Credentialing:
Responsible for Provider Initial and re-credentialing by auditing applications for
accuracy and completeness and using Prime source verification for license,
education, DEA and board certifications
Compiles and maintains current and accurate data for all providers.
Responsible for maintaining peer review schedules and compiling necessary
documents to present to the Medical or Dental Director for completion
AAAHC Accreditation:
Responsible for the coordination of AAAHC accreditation. Coordinates the
planning and implementation of the AAAHC survey by actively preparing and
participating in on-site surveys, coordinating agendas, and assigning
tasks, tracking activities
Leads accreditation/regulatory efforts in the planning and development of a
systematic, organization-wide approach to continuous regulatory readiness
Provides consultation and acts as a resource to leadership, managers, and staff on
accreditation and survey readiness
Provides recommendation for training and development opportunities to support
regulatory and accreditation readiness
Develops and revises policies and procedures to comply with current guidelines
and regulatory standards
Risk Management:
Develops, implements and annually reviews the Risk Management Plan
Manages complaints and grievances in relation to quality assurance
Manages the process of review and resolution of all incidents and potential or
actual adverse events
Ensures departmental leadership, maintains and documents full compliance with
safety regulations, disaster plans, emergency codes, infection control policies, fire
safety regulations, management of hazardous materials, and employee health and
infection control programs
Interprets new, revised, or upcoming regulations and standards and assists in
planning response
Responsible for evaluating patient satisfaction surveys and sharing the
information with Tribal council, Administration, Providers and Staff
Infection Prevention and Occupational Health:
Serves as the designated Infection Preventionist (IP) and Occupational Health
Nurse
The IP is certified and trained in Infection Prevention Control
Responsible for policies and procedures within the organization related to
infection control in the Medical and Dental departments and employee health
The IP provides consultation, education and training to staff and Physicians
regarding the Infection Control program
The IP oversees active monitoring and surveillance of Infection Control within
the facility
Ensures proper sterilization techniques and hygiene practices
The IP immediately implements corrective or preventative measures when
problems are identified
Manages the LVDHC employee vaccination records and is responsible for pre-
employment testing and vaccination processes, N95 fit testing, management of
blood exposures and employee illness
Coordinates preparation of departmental reports, studies, and audits
Must maintain confidentiality of all patient or client information
All other duties as assigned
QUALIFICATIONS:
Licensed or certified health care professional preferred (RN, LPN, CPQH etc.)
Certification in Infection Prevention or willingness to become certified
Experience in accreditation or regulatory survey process in a health care setting is
a must
A minimum of three years’ experience in health information, quality, or risk
management desired
Knowledge of relevant regulatory requirements
Experience with implementation of corrective action plans
WORK ENVIRONMENT/PHYSICAL DEMANDS
Fast paced with occasional high pressure or emergent situations
May wear PPE such as gloves or a mask
Frequent interaction with a diverse population including team members,
providers, patients, insurance companies and other members of the public
Frequent sitting, standing, walking, reaching, grasping, carrying, and speaking
Occasional bending, stooping, lifting less than 20 pounds
Lifting, carrying, pushing, and pulling up to 50 pounds, with assistance if needed
Frequent use of computer, keyboard, fax and copy machine, and telephone
This position is considered a sensitive position and is subject to drug and alcohol testing.
All offers of employment are conditional based on the applicant submitting to and
successfully passing a drug and alcohol screen which includes THC and future random
drug testing in accordance with LVDHC’s testing procedure.
Posting Expiration Date: May 5th, 2025
Preference will be given to qualified individuals of American Indian descent.
The above statements are intended to describe the general nature and level of work performed by people assigned to
this classification. They are not intended to be construed, as an exhaustive list of all responsibilities, duties and
skills required of personnel so classified. Management retains the right to add or to change the duties of the
position at any time. Must be able to pass a pre-employment drug screen and applicable background checks related
to the position.
Lac Vieux Desert Health Center Mission Statement: The Lac Vieux Desert Health
Center strives to provide excellence in health care and to inspire a culture of wellness.
Date Approved by the Tribal Council: 5/16/2019 Updated: 4/08/2025
LVD Health Center
Human Resources Department
P.O. Box 9, N5241 US 45
Watersmeet, MI 49969
Email: [email protected]
Website: http://www.lvdhc.org
Phone: 906-358-4587 Ext. 102
Fax: 906-358-4118
SIGNED: _________________________________________ DATE: ___________
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Title: Quality Assurance Coordinator
Company: Management & Training Corporation
Location: Bryan, TX
