Item 9.A-October 7, 2011
ADMINISTRATIVE FACULTY POSITION DESCRIPTION QUESTIONNAIRE
To expedite and facilitate the PDQ review process, please send the PDQ and Org Chart electronically to
marshag@unr.edu for discussion and for initial review before routing PDQ for approval signatures.
Questions - call UNR Faculty HR at 682-6114
INSTRUCTIONS: See http://www.unr.edu/vpaf/hr/compensation/placement.html for complete instructions.
Incumbent(s) Name (if applicable):
Position #(s):
Current Title: Chief Compliance/Quality Improvement Officer
Current Range: 4
(UNSoM)(JCC:86920;3H;CA3001;CC056;E)
Department: Dean’s Office - Reno
College/Division: University of Nevada
School of Medicine / VPHS
Account #(s): 1108-119-5031
Action Proposed: (check all that apply)
( ) New position: Proposed Range:
Proposed Title:
( ) Title Change, Proposed Title:
( ) Proposed Reassignment from Range
to Range
(X) Revised PDQ only (no change in range or title)
JCC (Current
( ) Line of Progression (show titles below)
or new HR
Range:
assigned):
I certify that the statements in this description are accurate and complete to the best of my knowledge.
____________________________________________________________
Employee’s Signature
__________________
Date
I/we have reviewed the statements in this form and they accurately reflect the job assignments.
____________________________________________________________
Immediate Supervisor’s Signature
__________________
Date
____________________________________________________________
Thomas Schwenk, Vice President, Health Sciences/Dean, UNSOM Date
Director/Chair/Dean
__________________
Approved for Salary Placement Committee review.
____________________________________________________________
__________________
Pres / Vice Pres / Vice Prov Signature Jannet Vreeland
Date
Vice Provost and Secretary of University
Action Approved by the President (Completed by Faculty HR):
Position #:
EEO Code: 3H
CUPA Code: CA3001
Exempt: Yes or No Census Code: 056
Job Class Code: 86920
Range: 4
Effective Date: 10/1/2011
Approved Title:
CHIEF COMPLIANCE/QUALITY IMPROVEMENT OFFICER (UNSoM)
____________________________________________________________
__________________
Employee Signature
Date
(Employee signs and sends to HR for personnel file after PDQ has been “final” stamped for approval)
Rev: 12/1/2008
Position Description – Chief Compliance/Quality Improvement Officer (UNSOM)
Page 2
1. Summary Statement: State the major function(s) of the position and its role in the
university. Attach an organizational chart with positions, ranges, and names for the division
which reflects the position in it as well as those supervised in the department. (This section is
used for advertisement of the position.)
Reporting to the Dean, the Chief Compliance/Quality Improvement Officer (CCO/QI) oversees the
University of Nevada School of Medicine (UNSOM), including the clinical practice corporations,
compliance program and coordinates and implements state wide Quality review programs working
closely with the Quality Review Committee. The Quality review Committee works with the Nevada
System of Higher Education risk manager to ensure clinical services are provided in accordance with
standards established through state and federal regulations and accrediting bodies. The CCO/QI is
responsible for developing and implementing a comprehensive compliance program, communicating
with executive management on the operation of the program and educating and training personnel in
all aspects of compliance. The CCO/QI develops a process to identify risk and exposure which
includes patient safety and quality of patient care, medical billing, research regulatory compliance,
Institutional Review Board (IRB) processes and documentation, health and safety, student exposures,
conflict of interest, information security, Health Insurance Portability and Accountability Act (HIPPA),
etc. The CCO/QI receives and directs compliance issues to appropriate resources for investigation
and resolution. This position serves as the UNSOM Health Insurance Portability and Accountability
Act (HIPAA) Privacy Officer.
2. List the major responsibilities, including percentage of time devoted to each. Provide
enough detail to enable a person outside the department to understand the job (percentage
first with heading and then bulleted information).
55% - Development and Management of Compliance Program
 Develop and implement a program to identify potential risks, collaborating with other
departments, including but not limited to the Quality Review Committee, Risk Management,
Campus Audit, Office of Sponsored Projects, Purchasing, General Counsel Develop, initiate,
maintain, revise, and monitor policies and procedures of the compliance program
 Establish and direct compliance helpline and other resources
 Establish and direct the clinical practice plan compliance audit schedule
 Respond to alleged violations of rules, regulations, policies, procedures and Standards of
Conduct by evaluating and, if warranted, recommending the initiation of investigative
procedures
 Direct issues to proper individuals for resolution and ensure resolutions take place in a timely
and effective manner
20% - Development and Management of Quality Improvement Program
 Under direction of the UNSOM Quality Review Committee develops and fully implements a
program which is a comprehensive patient safety/quality/performance improvement program
inclusive of the collection, analysis and trending of data.
 Regularly communicates through General Counsel to The Nevada System of Higher
Education risk manager issues of potential or existing claims (both professional and general
liability) and/or litigations
 In conjunction with the UNSOM Quality Review Committee and system leadership directs and
coordinates proactive and reactive patient safety activities including root cause analyses and
failure mode effects analyses
 Responsible for the strategic direction of UNSOM’s quality improvement program by
designing, developing, implementing and conducting ongoing evaluation of the quality review
program activities
Position Description – Chief Compliance/Quality Improvement Officer (UNSOM)
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25% - Education / Communication
 Institute and maintain an effective compliance communication program for the organization
including promoting the use of a helpline, heighten awareness of standards of conduct and
understanding of new and existing compliance issues and related policies and procedures
 Communicate school expectations and codes of conduct as developed and revised
 Provide reports on a regular basis to keep all necessary parties (Dean, Board of Integrated
Clinical Service (ICS), Quality Review Committee, etc.) informed of the operation and progress
of compliance efforts
 Work with Human Resources and other offices to develop an effective compliance training
program, including introductory and ongoing training
 Develop educational strategies and:
o Determine what materials and in what context to include policies and procedures in
training manuals
o Prepare all training materials for electronic and classroom compliance training modules
o Determine dates for training and appropriately advertise training sessions to achieve
maximum participation
3. Describe the level of freedom to take action and make decisions with or without
supervision and how the results of the work performed impact the department, division and/or
the university as a whole.
The CCO/QI is responsible for the development and management of the UNSoM compliance
program. The CCO/QI works collaboratively with senior management, faculty and staff to identify
potential areas of risk and vulnerability. The individual is the key person to ensure an effective
program is implemented and maintained. The CCO/QI reports directly to the ICS Board and the Dean
on the compliance program and current areas of concern. The position maintains independence to
ensure clear and objective observations and decisions are made and confidentiality, when
appropriate, is maintained. Decisions and judgments made by the CCO/QI may have significant
impact on the conduct of all personnel within UNSoM. Failure to implement and maintain a
comprehensive Compliance program may subject the UNSOM and its clinical practice to fines or other
punitive actions. Grant funding could also be withdrawn if appropriate compliance actions are not
made. Timeliness, accuracy and clarity of communication are essential.
4. Describe the knowledge, skills (to include cognitive requirement and verbal and written
communication), and abilities (to include task complexity, problem solving, creativity and
innovation) essential to successful performance of this job (in bullet format).
Knowledge of:
 Codes of Conduct for clinical and research faculty and staff
 Health Care – medical billings and claims, Medicare and Medicaid, resident attending
services, patient referrals, HIPAA, patient care, etc
 Research – clinical trials, research integrity, federal and state regulations, conflict of interest,
IRB, effort reporting, export controls, etc.
 Health and Safety – compliance with safety standards, hazardous materials, emergency
preparedness preparation, etc
 Human resource management procedures and policies, Fair Labor Standards Act (FLSA),
HIPAA, other regulations, etc.
Position Description – Chief Compliance/Quality Improvement Officer (UNSOM)
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Skills:
 Assessing risk and communicating to general public
 Human resources management and supervisory skills
 Management of highly complex programs and provide timely solutions in a constantly
changing environment
 Training
 Program development and management
 Effective oral and written communication
 Strong interpersonal skills to include working with diverse groups of individuals and building
partnerships
 Analytical, problem solving, organizational and management skills
 Attention to detail and accuracy
Ability to:
 Maintain confidentiality of information
 Take initiative and work independently, as well as ability to work collaboratively and build a
successful team environment
 Motivate others
 Maintain professional business and work ethics and standards
 Act as authority in area of expertise
 Appropriately determine priorities in order to manage a multitude of projects with various
timelines, deadlines and needs
 Research issues/situations, develop and provide solutions, exercise sound judgment to make
appropriate decisions, and implement solutions reflective of the university’s mission and
commitment to diversity; bring concerns to management
 Travel as required
5. Describe the type of personal contacts encountered in performing the duties of the job.
Explain the nature and purpose of these contacts: i.e., to provide services, to resolve
problems, to negotiate.
Internal
UNSOM Dean, ICS Board,
Department Chairs, Associate
Deans and other administrative
leaders
UNSoM faculty, medical
residents, staff and Practice Plan
Staff
Reason for Contact
To assess, develop, and implement a compliance program and to
provide timely, appropriate, and accurate information relative to
the compliance program
University Administration
To share information and problem solve
External
Auditors
Reason for Contact
To identify issues requiring attention, assist in investigations,
Outside entities
To discuss insurance issues, billings, vendors, healthcare finance
and regulatory issues
To assess and develop programs and provide training for
individuals who may also be selected to perform the training on
behalf of the CCO
Position Description – Chief Compliance/Quality Improvement Officer (UNSOM)
Page 5
6. Indicate the minimum qualifications which are necessary in filling this position should it
become vacant. Please keep in mind the duties/responsibilities of the position rather than the
qualifications of the incumbent.
a.
Minimum educational level, including appropriate field, if any.
Bachelor’s Degree from a regionally accredited institution in health related field
b.
Minimum type and amount of work experience, in addition to the above required
education necessary for a person entering this position.
Bachelor’s Degree and five years or a Master’s Degree and three years of experience
in a healthcare, research or academic environment; coordinating, organizing and
implementing programs
Preferred Licenses or Certifications: None
c.
Indicate any license or certificate required for this position.
None