Director of Quality Assurance and Compliance

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Job Summary :

The Director of Quality Assurance and Compliance is responsible for the overall development, implementation, and management of the Agency Quality Assurance and Compliance Program.

Responsible for the maintenance of and adherence to the organization’s policies and procedures covering the privacy and access to client clinical information licensing and accreditation, in accordance with federal and state laws and agency requirements.

Coordinates and monitors all compliance activities and programs and quality improvement activities.

Duties and Responsibilities :

I. Compliance

• Overseeing and monitoring the implementation of the compliance programs : including privacy and access to client records, and serves as agency Ombudsperson for client satisfaction, perception of care inquiries.
• Works with legal counsel and leadership, key departments and committees to ensure the organization has and maintains appropriate privacy and confidentiality consent, authorization forms and information notices and materials reflecting current organization and legal practices and requirements.
• Periodically updates policies and procedures to maintain compliance with laws and regulatory authorities.
• Coordinates and facilitates annual review of agency-wide policies and procedure manuals (AP, HP, and CP Administrative, HIPAA / HITECH, and clinical) with summary reports for the annual review by the Strategic Planning Committee of the Board and the Board of Trustees.

Developing policies and programs that ensure protocol are in place and staff have options to report suspected fraud and other improprieties without fear of retaliation.

• Complete False Claims paperwork (Section 6032 Federal Deficit Reduction Act) for review and sign off by the Executive Director for submission to the Office of the State Comptroller, Medicaid Fraud Division on a yearly basis.
• Investigates matters related to compliance in accordance with legal guidance and agency policy and procedure. Prepares reports and recommendations in accordance with directives from legal leadership.
• Investigates client complaints with Human Resources and legal as necessary to resolve concerns and improve quality of care.
• Assists Leadership and designees coordinating internal compliance reviews.
• Develops and implements training programs regarding compliance.
• Manages incident reporting process to ensure proper and timely reporting.

II. Agency-wide Accreditation

• Responsible for the agency-wide accreditation by maintaining up-to-date on accreditation standards / systems / processes in order to maintain and exceed accreditation expectations.
• Provides educational training, both group and individual, to ensure staff knowledge with the accreditation standards. Complete mock surveys as requested.
• Develops, coordinates, and facilitates all accreditation site survey review documentation both documentation for the accreditation portal as well as on-site documentation.
• Develops accreditation site review schedule to facilitate the effective and efficient use of reviewers.
• Completes the yearly Maintenance of Accreditation report yearly in order to maintain accreditation.
• Reports all critical incidents and records in accreditation portal.

III. Licensing, Medicare / Medicaid Reviews

• Responsible for the coordination and facilitation of all licensing reviews.
• Provides guidance and training to facilities and security staff for compliance and licensure preparation.
• Provides education and training to departmental staff as it relates to licensing regulation compliance.
• Initiates on-site reviews of program sites prior to licensing visits to ensure compliance.
• Escorts licensing review team from site to site in order to assist reviewers in understanding our programs / sites.
• Coordinates and completes the Plan of Correction for Licensing.
• Facilitates Medicare / Medicaid reviews and coordinates and completes the plan of correction.

IV. Quality Improvement

• Responsible for the direction of the agency-wide Quality Improvement Program in accordance with agency’s mission, accrediting / licensing requirements, and agency’s strategic plan.
• Chairperson of the Agency-wide Quality Improvement Committee as Quality Improvement subcommittees.
• Provides training on Logic Model / PDSA / CQI as needed.
• Compiles and presents quarterly QI / Logic Model / PDSA reports to the Strategic Planning committee of the board for presentation to the Board of Trustees.
• Serves as secretary to the Consumer Advisory Committee.
• Coordinates, completes, and uploads CCUSA Program Detail Report, Core Services Report, and CLINIC Immigration reports yearly.

V. Utilization Management

• Supervises Utilization Review staff as it relates to data collection, report generation, and timely reporting.
• Supervises and directs periodic audits as needed to identify areas in need of improvement.

VI. Risk Management and Safety

• Manages Risk Management Program by reviewing all incident reports and flagging and monitoring those that need additional action steps and rapid cycle PDSA.
• Manages risk management insurance program serving as liaison to the Chancery on insurance matters and renewals.
• Via incident reporting system, notify and / or send reminder to directors when case reviews are needed.
• Report all critical incidents to accrediting group, if required.
• Chairperson of the Agency Safety Committee as well as the Mercer Campus Safety Subcommittee.
• Develop agenda for the Safety Committee and utilizes Risk Management Incident report to develop PDSA and other actions steps needed by Maintenance / Programs.
• Investigates incidents and responds to any OSHA complaints.
• Serves as member of COVID workgroup to address pandemic-related issues.

VII. Health Information Management and Reporting

• Manages EHR Clinical system to ensure compliance and reporting functionality.
• Oversees training resources for clinical modules of EHR.
• Assists with reporting functionality and training of EHR.
• Ensures EHR maintains compliance with level of care licensing standards.
• Conducts system audits to ensure proper functionality of EHR.

Job Relationships :

• Reports to Executive Director.
• Works in close collaboration with the Service Area Directors and their designees, Leadership and their designees, and support agency committees as appropriate.
• Maintain professional relationship with licensing and accrediting agencies and serves as a liaison between the programs and the licensing / accrediting bodies.

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