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Director Policy and Outcomes Management

  • Full Time
  • Atlanta

Emory Transplant Center

Emory Transplant Center seeks a highly motivated, self-directed, critical thinking, and respected transplant professional with quality and regulatory management experience, coupled with a passion and commitment to guide transplant program, Center, and institutional leadership through the ever-changing regulatory waters of transplantation. For more information contact Sr. Transplant Center Administrator, Anjali Basu,

Director, Policy and Outcomes Management

DESCRIPTION:  Responsible for ensuring the Emory Transplant Center (ETC) and its programs remain compliant with Centers for Medicare and Medicaid Services (CMS), Organ Procurement and Transplantation Network (OPTN)/United Network for Organ Sharing (UNOS), the State of Georgia and The Joint Commission (TJC) regulations specific to organ transplant and organ donation. Develops processes to monitor metrics and audit reports to ensure data integrity, policy compliance, and patient safety reporting both internally and externally, to appropriate regulatory and oversight committees and their agencies. Oversees the monitoring and reporting to ensure ongoing compliance with OPTN/UNOS and CMS.  Provides oversight to ensure thorough, accurate preparation and submission of all regulatory agency “Requests for Information” (RFI) for clinical approvals of the programs including but not limited to: UNOS key personnel change applications, OPTN/UNOS MPSC inquiries, OPTN/UNOS and CMS survey findings with development and submission of realistic and appropriate plans of correction (PoC). Keeps abreast of regulatory changes and communicates any new requirement concerns to ETC’s Executive Director(s) and Senior Center Administrator. Collaborates with ETC and program leadership and quality staff on policy and procedure development or revisions. Works collaboratively with each program’s administrative, medical, and surgical directors and ETC quality leadership to ensure survey readiness.

Primary liaison and contact of OPTN/UNOS and CMS.  Responsible for regulatory compliance with CMS, UNOS, State of Georgia, and other bodies that regulate and grant approval/certification for our center to perform solid organ transplants. Represents ETC leadership along with the clinical program managers during surveys from CMS, UNOS, and TJC. Provides design and oversight for chart audits and documentation to identify regulatory gaps for performance improvement. Oversees and manages CMS and OPTN/UNOS QAPI requirements. Manages all communication and requests from CMS and OPTN/UNOS.  Oversees all UNOS reporting (e.g., key personnel change applications, organ allocation investigations, patient safety reporting, outcomes compliance reporting).  Primary liaison to hospital leadership for transplant regulatory compliance and policy management.

Collaborates with transplant program leadership on Center policy and procedure development, review, and revisions specific to regulatory compliance. Maintains currency in CMS, UNOS, and State of Georgia transplant requirements and collaborates with key personnel to implement necessary operational changes.  Works directly with faculty and staff to implement policies and procedures to ensure compliance with regulations.

Collaborates with clinical managers to oversee accuracy of outcomes data submitted by program staff to UNOS for SRTR. Collaborates with quality/regulatory specialist to proactively track and identify changes in SRTR data to program leadership. Works with the quality team on adverse events, investigations, reporting and action plans.

Takes the lead with clinical managers in development of materials for surveys and all follow-up requirements after surveys including corrective actions plans, policy and procedure edits, and any other necessary required actions. Guides transplant program leadership, nursing, medical and surgical directors regarding strategies to ensure good standing with regulatory agencies. Educates staff about compliance with new and revised guidelines and regulations, or findings from internal audits. Works with the clinical programs to develop appropriate regulatory compliance orientation education for all new hires.

Manages staff and employee performance. Plans, assigns and directs work. Provides ongoing performance feedback, addresses problems, orients and trains new employees and resolves human resource related issues.

MINIMUM QUALIFICATIONS:  A baccalaureate degree in nursing, public health, healthcare administration, nursing or related field required. Master’s degree is preferred. Current RN licensure in the state currently practicing. Five years of healthcare experience in clinical nursing, public health, and/or healthcare policy required. Transplant regulatory compliance and quality experience preferred.

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