Quality Compliance Manager

Job Description

Job Description

About the role

The Quality Compliance Manager assists with the quality function, including supporting quality improvement, compliance, and data management initiatives to meet the Agency’s continuous quality improvement standards.

The Manager identifies risks via internal monitoring and coordinates on-site audits per contract requirements. This is a salaried management position.

This employee assigns and supervises all staff in his / her program(s) and is accountable for the quality of program life and the staff and youth decisions and actions within each program, under Spectrum Juvenile Justice Service’s mission statement, policies and procedures, professional Code of Ethics, State of Michigan licensing, contracts, funding, and CARF standards.

Qualifications

• Bachelor’s Degree in a Human Service Discipline (Social Work, Psychology, or related field).
• Preferred : Michigan licensure as a master’s level clinician with either limited or full licensure (LLPC / LPC, LLMSW / LMSW, TLLP / LLP).
• Three years of experience in a quality improvement analyst or Quality control program management position within a health care or human service organization.
• Two years of management experience.

General Responsibilities

• Leads preparation for licensing renewals / audits / contract audits; serves as the point of contact for onsite reviews, preparation for the reviews, license renewal, and coordination plan of correction submission.
• Leads monitoring efforts campus-wide - internal monitoring of Youth files, plans of correction, State of Michigan KPIs, and agency KPIs to ensure licensing and contract compliance
• Supports the agency reporting requirements internal agency reporting of risk measures, quality activities, program metrics
• Coordinates all agency policy maintenance, participates in Standards Committee
• Conducts Quality training related to HIPAA, licensing compliance, and other quality initiatives
• Support survey development and evaluation opportunities.
• Assists in developing quality-related action plans to support the agency’s annual and strategic planning process.
• Actively participates in the accreditation / re-accreditation (CARF) process and helps ensure that the Agency plans and implements a thorough response when standards change.
• Coordinates regular (monthly and quarterly) file audits.
• Coordinates utilization management within programming to ensure appropriateness and efficiency
• Participates in implementing key Qualify efforts, including, but not limited to, ensuring HIPAA compliance and incident reporting.
• Promote the use of data, data quality, and process improvement
• Actively participates in the implementation process of the Youth Relationship Management system.
• Participates in Utilization Review Meetings to aid team members in delivering the highest-quality care and services.

Youth Complaint Resolution

• Advises youths of their rights, reviews youth materials, and provides updates as necessary.
• Monitors maintains and responds to Youth concerns and complaints provided through the internal system.
• Conducts all investigations required under the Youth Rights Program promptly and completes all required documentation.
• Makes necessary recommendations / reports to the Executive Director, Human Resources, and external partners as necessary.
• Develops and finalizes corrective action plans (CAPs) following substantiated complaints. Monitors compliance with action plan requirements.

Youth Service and Youth Rights Training

• Conducts all Youth Satisfaction Survey compilation and reporting.
• Conducts onboarding and annual training for all staff and volunteers on Youth Rights, the Child Protection Law (including Mandated Reporting guidelines), Consumer Rights, and Prison Rape Elimination Act (PREA).
• Stays informed of current practice development within the profession of Youth service and Youth rights issues and uses educational and training opportunities to ensure continual professional competence.
• Coordinates with the Training Manager and conducts training for all staff on Youth Service, Confidentiality, and HIPAA.

Youth Advocacy and Quality Improvement

• Reviews all completed incident reports, assesses data according to the severity of the incident, monitors for trends, and aids in developing improvement plans.
• Works with youth and builds supervision to establish regular youth advisory council meetings. Aids youth in the development of recommendations for improvement.
• Reports recommendations to Senior Leadership and aids in implementing changes based on Youth feedback.
• Participates in continuous quality improvement efforts.
• Demonstrates personal integrity and professional demeanor following the agency's and profession's ethics.
• Regularly enters all critical restraint and seclusion incident information into the MISACWIS database.
• Serves as the Compliance Officer by completing investigations and reporting.
• Demonstrated ability to plan and organize work to meet all job requirements under applicable regulations, safety rules, and agency and professional standards.
• Performs all other duties as required or requested, keeping within the scope of this position.

Case Management

• The Youth Rights & Compliance Manager carries a full caseload and the above-stated responsibilities.
9 days ago