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Director of Compliance, Quality Assurance and Accreditation
3 months ago
Job purpose
The Director of Compliance, Quality Assurance and Accreditation leads the compliance, regulatory, accreditation and licensing functions for Meridian Behavioral Health. This position is responsible for maintaining positive working relationships with the interdepartmental teams, regulatory entities, accreditors and associated vendor partners. This position oversees Company quality assurance and improvement activities to ensure that all locations are performing at the highest standard and complying with state, federal and Company laws, regulations and organizational policies. In addition, the Director is also responsible for leading the Company through the process to obtain international accreditation from the Commission on Accreditation of Rehabilitation Facilities (CARF) or a similar entity.
Duties and responsibilities
The following duties are normal for this position. These are not to be construed as exclusive or all-inclusive. Other duties may be required and assigned.
- Develops, initiates, maintains and revises policies and procedures for quality and compliance program and its related activities to comply with MN Department of Human Services and MN Department of Health guidelines.
- Maintains databases that track Critical Incidents, client grievances, director reports and others to identify areas needing improvement.
- Track, analyze and assist in improving assigned scorecard elements in collaboration with the Chief Operating Officer.
- Ensures compliance with contractual requirements and federal, state, and local government regulations, MN Department of Human Services, MN Department of Health, etc.
- Familiar with auditing programs such as CARF, MN Quality Assurance, MN Statute 245G and related practices, and procedures within the Mental Health and Chemical Dependency field.
- Ensures proper reporting of violations or potential violations to duly authorized enforcement agencies as appropriate or required.
- Maintain, update and periodically review Policy and Procedure Manual by MN Department of Human Services and MN Department of Health guidelines, insurers, and others.
- Collaborate with other departments to direct compliance issues to appropriate existing channels for investigation and resolution.
- Provide compliance and privacy training to new employees and ongoing training to employees according to new statute, regulatory changes and policy enhancements.
- Provides input in the development of company-wide Quality Improvement (QI) process and philosophy.
- Provides expertise in design, data collection, aggregation and display of all quality activities and initiatives.
- Manage projects and coordinate company-wide quality improvement projects.
- Monitor annual compliance and privacy training.
- Provide reports on a regular basis and informs senior management of the operation and progress of compliance efforts.
- Maintains logs, indexes, files, computer databases and other records pertaining to compliance requirements.
- Collects data from internal and external audits and quality improvement programs.
- Maintains files of communications and reference materials with regulatory agencies.
- Maintains and disseminates documentation and reports pertaining to quality and compliance issues, procedures, processes and methodologies.
- All other duties as assigned by executive leadership.
Qualifications Required to Perform Essential Job Functions:
- Bachelor’s degree preferred in business, behavioral science, health care or mental/chemical health; and/or 5+ years of experience in quality improvements methods such as: Six-Sigma, Lean, Black Belt or green belt certification in a health care setting.
- 5+ years of Quality Improvement and Compliance experience, in a health care organization preferred.
- Leadership and administrative skills.
- Possess a valid driver license and vehicle as will travel to various company sites.
- Must know or be willing to receive training on all parts and the implications of MN Statute 245G as well as all other required rules and regulations.
Required Skills, Knowledge and Ability
- Strong verbal skills and ability to communicate with a variety of people from diverse cultures, socioeconomic and educational backgrounds.
- Flexibility to meet organizational needs.
- Proficient in MS Suite: Outlook, Excel Word and Power Point, (Alleva, Procentive EMR experience preferred).
- Strong critical thinking, communication, and problem-solving skills.
- Ability to work and collaborate with a diverse network of both internal and external groups and/or individuals.
- Strong interpersonal and communication skills, both written and verbal.
- Must be self- motivated and able to manage multiple projects with key deadlines and direct, guide compliance team accordingly.
- Have the ability to work independently with minimal direction, while working collaboratively with the associated departments; in particular clinical services, operations and human resources.
- Detail oriented; able to process, interpret regulatory standards, requirements and convert/translate into appropriate vernacular/jargon for all staff to understand and behave accordingly.
Preferred Qualifications and Skills
- Ability to navigate fast paced, high demand, energy work settings.
- Experience enhancing, revamping compliance department and implementing associated practices.
- Experience with digital learning and assessment management systems, including designing and using complex learning and assessment feedback processes in digital environments.
