POSITION TITLE: Director of Quality & Compliance
REPORTS TO: Chief Executive Officer
PRIMARY DUTY
Responsible for overseeing the effectiveness, operation, administration and management of facility compliance. Responsible for integrating strategic plans into all compliance operations, providing transformational leadership and direction to develop, recommend and implement compliance programs that meet, regulatory and accrediting bodies policies and procedures. Assumes direct compliance support accountability for all entities.
ESSENTIAL JOB FUNCTIONS include the following.
- Promotes the mission, vision, and values of the organization
- Disseminates information to and educates employees regarding a broad spectrum of compliance related topics
- Maintains a current working knowledge of applicable Federal, State and Accreditation regulations and policies
- Oversee fully the electronic medical records and learning management systems
- Provides education and training about actual, proposed, or pending legislation and regulations that affect operations, identifies operational obstacles to compliance, and works with executive team to identify and implement solutions
- Leads the company through CARF / Joint Commission, State and Federal accreditation and regulatory processes.
- Reports to the executive team on compliance-related matters as appropriate or whenever called upon to do so
- Creates, implements and maintains applicable policies and procedures
- Monitors compliance by conducting routine and/or focused internal audits of policy/procedure adherence as well as coordinating audits generated by external sources
- Develops, coordinates and participates in routine educational and training programs that focus on the elements of the Compliance Program thus striving to ensure that all appropriate employees and management are knowledgeable of, and comply with, applicable Federal and State program requirements
- Coordinates of follow-up and resolution to compliance reports/inquiries
- Access Coordinator as per 105.CMR.164
- Develops and maintains image as a key player and ethical voice in related health care issues through participation in industry organizations
EDUCATION and EXPERIENCE
Master’s degree in Public Health, Health Care Administration or related field required
- 3-5 years of upper management experience in health or behavioral health setting required
- Experience with the CARF / Joint Commission of Accreditation Standards
- Experience with Learning and Development Applications
- Experience with Electronic Medical Record compliance monitoring and reporting
- 3+ years experience in health care corporate compliance
- A high degree of organizational, analytics, decision- making and creative thinking skills required
- an equivalent combination of education, training and experience will be considered.
SUPERVISORY REQUIREMENTS of this position are generally as follows:
- This position does not require direct supervisory responsibilities
KNOWLEDGE, SKILLS and ABILITIES
- Must be detail oriented
- Able to work under pressure and meet deadlines as well as be flexible and dependable
- Strong interpersonal, organizational and analytical skills
- Structure and content of the English language including the meaning and spelling of words, rules of composition, and grammar
- Identifying complex problems and reviewing related information to develop and evaluate options and implement solutions
- Considering the relative costs and benefits of potential actions to choose the most appropriate one
- Ability to handle multiple priorities with a sense of urgency
- Excellent interpersonal communication (verbal and written)
- Listen to and understand information and ideas presented through verbal and written words
- Communicate information and ideas verbally and in writing so others will understand
- Identify/recognize when something is wrong or is likely to go wrong and know who to involve for resolution
COMPUTER SKILLS/EQUIPMENT USED TO PERFORM THE JOB
• Desktop computers, fax machines, scanners, copiers
- MS Office (Word, Excel, Outlook)
- Multi-line telephone systems
- EMR software
HIPAA PRIVACY TRAINING & SANCTIONS
All employees who have access to health information whose confidentiality is protected by the HIPAA Privacy Rule are required by the Rule to receive training so that they have an understanding and knowledge of the Privacy Rule that corresponds to their job responsibilities and of the group health plan’s policies and procedures that impact on their job duties. Site specific training on requirements of the HIPAA Privacy Rule and the plan’s health information policies and procedures under the direction of the plan privacy officer may be required for this position based upon site specific requirement. Employees who violate the requirements of the HIPAA Privacy Rule will be subject to discipline, up to and including termination.
BENEFITS & SALARY RANGE $80,000 – $100,000
401 K, Health, Dental and Life Insurance, Tuition reimbursement for job related training Workmen’s Compensation and a Time off plan.
This job description in no way states or implies that these are the only duties to be performed by the employee occupying this position. Employees may be required to follow other job-related instructions and to perform other job-related duties as requested, subject to all applicable state and federal laws.
Certain job functions described herein may be subject to possible modification in accordance with applicable state and federal laws. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.