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Reports to the Director of Compliance and Quality Management. This position is responsible for assisting the Director with the daily operations of the Quality Management (QM)/Compliance department, including assisting with the supervision of staff and the delegation of departmental tasks. Duties include collaboration with the Director for oversight and monitoring of the Agency quality management, risk, compliance, medical records, and Human Rights systems, including: implementation of Agency performance indicator data and reporting; auditing; support of service planning systems; facilitate/lead Continuous Quality Improvement projects, and development of systems to monitor QM departmental responsibilities. Responsible to ensure Agency compliance with state and federal laws and regulations as they relate to privacy and compliance.
Essential Duties and Responsibilities:
- As part of ongoing efforts for Continuous Quality Improvement, assists the Director with identifying short-term and long-term plans/goals for the QM/Compliance department, within the context of the agency’s strategic long range and Compliance Plans.
- Participates in the recruitment and hiring of departmental staff as assigned by the Director and provides support with training, supervision, evaluations, and corrective action.
- Assists the Director in the oversight of day-to-day operations of QM/Compliance departmental tasks and in the Director’s absence, is responsible for the administrative supervision of departmental staff.
- Supports the Director in the oversight of the fact-finding and reporting processes for complaints related to Human Rights and DPPC issues, including facilitating contacts with relevant contacts at state agencies and coordinating with Operations and Human Resources to facilitate rapid turnaround of investigation findings.
- Supports the Director in the oversight and completion of all aspects of the ambulatory division’s productivity process. This includes data entry, analysis, reporting, and other productivity duties as assigned.
- Supports the Director in the oversight of the auditing and reporting process in the ambulatory division. This includes intake audits, user activity audits, and facilitating audits from external stakeholders.
- Supports the Director with risk management processes.
- Supports the Director in the implementation of internal monitoring systems for compliance with federal and state healthcare regulations. This includes training the workforce, auditing programs, and providing ongoing support to programs as needed.
- Assists the Director in identification of training needs of QM/Compliance departmental staff.
- Oversees the management of monthly Quality Indicator data collection, data entry, and report development and distribution. Includes collaborating with departmental managers to set deadlines for receipt of indicator data, and assuring timely data entry among QM Supports departmental managers with updating data collection systems as needed.
- Assists the Director in developing and managing use of database systems, identifying training needs of QM/Compliance staff related to database management, and developing performance improvement projects related to data management, reporting and compliance standards.
- Facilitates QM data meetings and assigns and tracks follow up as indicated.
- Identifies strengths, weaknesses, and areas for development based on Quality Management data. Tracks the implementation and success of management actions designed to improve program outcomes, solve problems, or enhance services.
- Coordinates with the Director of Developmental Services (DS) to ensure compliance with Department of Developmental Services (DDS) Survey and Certification standards, as well as the operational standards of NSMHA, DDS and MCB, and develops audits, reports, and follow up systems regarding areas in need of improvement.
- Supports the DS department with Survey and Certification processes and may act as the secondary liaison to the DDS Survey and Certification auditing team.
- Oversees performance indicator and audit data collection and reporting process for DS programs, tracks follow up, and acts as primary QM contact for the DS Department regarding these activities.
- Acts as an access administrator for the Virtual Gateway, including the registering and deactivation of staff.
- Trains new managers (RSCs, PCs, and APCs) on Quality Enhancement Systems.
- Provides ongoing training and resources related to community activities and community integration efforts, including the facilitation of Community Integration Forums.
- Uses data to define and recommend short-term and long-term plans for programs within the context of the agency’s strategic long range/Compliance Plans (services, funding, grant writing, etc.).
- Attends standing Agency committee meetings as assigned, tracks attendance, takes minutes and distributes to all relevant staff.
- Participates as needed in meetings and committees with state agencies and trade associations, including DDS, DMH, and MCB, as well as ADDP, the Providers’ Council and ABH.
- Monitors program/site compliance practices are achieved through training and auditing as needed to assure consistency with applicable standards (i.e., licensing, certification, and other compliance standards).
- Prepares reports related to monitoring and compliance activities as needed.
- Assists the Director in researching, writing, and implementing organizational policies related to compliance, quality, and other topics as assigned.
- Performs other duties as assigned.
Minimum Bachelor’s degree required. Minimum eight (8) years of experience in healthcare, two (2) of which must be supervisory. Proven experience in the monitoring and management of community based, residential, and ambulatory programs.