About this role
Essential Duties and Responsibilities
Regulatory Compliance and Oversight
• Ensure facility operations comply with CMS Conditions for Coverage, Georgia Department of Community Health requirements, ESRD Network expectations, and applicable organizational policies.
• Maintain readiness for CMS certification surveys, state inspections, and accreditation reviews.
• Ensure required licenses, certifications, permits, policies, and documentation are current.
• Monitor compliance with infection prevention, water quality standards, equipment maintenance, emergency preparedness, and patient safety requirements.
• Ensure required reporting is completed accurately and timely.
Leadership and Operations Management
• Provide overall administrative leadership for daily dialysis facility operations.
• Develop, implement, and evaluate operational processes to support safe and efficient patient care.
• Establish priorities and accountability for staff performance.
• Participate in strategic planning, budgeting, and resource management.
• Identify operational barriers and implement corrective actions.
Quality Improvement and Performance Improvement (QAPI)
• Partner with the Medical Director and interdisciplinary team to develop, implement, and monitor the Quality Assessment and Performance Improvement (QAPI) program.
• Review quality metrics including:
• Dialysis adequacy
• Vascular access outcomes
• Infection rates
• Hospitalizations and mortality trends
• Patient experience measures
• CMS Quality Incentive Program (QIP) measures
• Ensure action plans are developed and sustained when performance goals are not met.
Patient Care and Safety
• Promote a patient-centered care environment focused on dignity, respect, and safety.
• Ensure patient rights are protected and complaints/grievances are addressed timely.
• Support patient education and adherence initiatives.
• Ensure emergency preparedness plans are maintained and tested.
• Promote safe dialysis practices and reduction of adverse events.
Human Resources and Staff Management
• Recruit, retain, train, and develop qualified dialysis personnel.
• Ensure staff meet required qualifications, competencies, and annual training requirements.
• Conduct performance evaluations and address performance concerns appropriately.
• Promote teamwork, communication, and professional accountability.
• Ensure adequate staffing levels to support safe patient care.
Financial Management
• Assist with development and management of the facility operating budget.
• Monitor productivity, staffing expenses, supply utilization, and operational expenses.
• Identify opportunities for cost-effective improvements while maintaining quality care.
• Participate in capital planning and equipment replacement needs.
Medical Staff and Interdisciplinary Collaboration
• Collaborate with the Medical Director to ensure appropriate clinical oversight.
• Support effective communication among physicians, nurses, dietitians, social workers, and technicians.
• Facilitate interdisciplinary team meetings and follow-up on identified patient needs.
Documentation and Reporting
• Ensure accurate and timely completion of required facility documentation.
• Maintain records required for regulatory compliance and operational oversight.
• Review audits and implement corrective actions as needed.