Job Type Full-timeDescriptionGeneral Summary:The purpose of this position is to serve as an integral member of the Compliance department team to educate the agency on local, state, and federal regulations, create systems of accountability, and report agency performance. This person will monitor patient and stakeholder satisfaction; maintain the compliance calendar and provide reminders to the compliance team and other agency personnel when regulatory and accreditation items are due; coordinate and schedule compliance audits, Health and Safety requirements, regulatory audits, and accreditation site visits; facilitate organizational communication of audits, results, and action plans.Essential Duties and Responsibilities:
- Responsible for completing a daily expectation of chart reviews on open and closed cases, considering client care, standards, and procedure compliance.
- Evaluate documentation patterns and collaborate with department leaders in training, clinical, and compliance to create and implement necessary action plans
- Serve as point person for the department in following up with clinicians and managers who have not submitted necessary training or compliance documentation.
- Schedules and supports internal Audits in conjunction with the Compliance Manager
- Performing site visits to Zepf locations for policy conformance, documenting findings, and reporting to supervisors for correction or modification.
- Works with compliance team and other staff members to prepare for regulatory audits and accreditation site visits to ensure accuracy to limit agency financial loss.
- Assists in maintaining required documents needed for regulatory and accreditation entities are up to date and readily available for unannounced site visits.
- Initiates and works with Compliance Manager and other staff members in the agency to ensure applications are completed accurately and sent to the regulatory entities in a timely manner.
- Identifies items needed for the site visit, works with staff members to identify who is responsible for missing items. Sets up Outlook reminders to ensure items are received timely.
- Informs the Sr. Compliance Director, and/or other supervisors when items are not received on time.
- Participates in agency-wide projects and staff development; carries out policies and procedures of agency.
- Works with the Compliance Department and Health Information Technology (HIT) team and others to analyze data and complete required agency and external reporting requirements.
- Supports Clinical Coordinator in monitoring and tracking corrective action plans, audit recommendations, and quality improvement projects to ensure implementation, effectiveness, and completion.
- Facilitates post-audit communication/debriefings to identify areas for improvement based on feedback received.
- Coordinates formal corrective action plans and/or quality improvement projects as needed.
- Monitors and communicates with staff as needed to ensure follow-up action is taken to ensure Corrective Action Plans (CAP)s and Quality Improvement Plans (QIP)s are fully implemented and followed through until completed.
- Assists leaders in developing and implementing corrective action plans related to metrics set forth by the agency or external auditing bodies.
- Works with compliance team and the agency Training Director to provide training to meet regulatory and accreditation standards.
- Identifies annual training needs and provides information to the Training Director to set the calendar.
- Prepares presentation and provides training as required during new hire orientation to departments within the organization.
- Research materials to incorporate into the training.
- Creates, or works with others, to create training materials
- Communicates with people outside the organization, representing the organization to customers, the public, government, and other external sources.
- Fills in for other members of the compliance team to ensure agency needs and regulatory requirements are met.
- Stays up to date on state and federal compliance regulations along with local clinical care standards.
- Identifies and assesses significant business risks through managing and reporting compliance reaches and exposures.
- Assist with compliance investigations stemming from reported incidents.
- Supporting various departments by collecting and coordinating compliance data Ensuring complete, accurate and timely data to all correct parties.
- Assist the agency with Sanctuary implementation, advise on trauma-organized guidelines, agency and department with privacy functions; HIPAA, risk assessments and staff/client updates
- Perform other duties as assigned.
Specific/Individual Competencies:
- High attention to detail and able to draw conclusions and guidance based on regulations.
- Ability to work independently as well as cooperatively within teams.
- Ability to write clear, concise, accurate and grammatically correct documents/reports.
- Use of discretion regarding sensitive and confidential information.
- Ability to plan and organize time and tasks to meet timelines; ability to prioritize and adapt quickly to changing needs.
- Ability to maintain office equipment.
- Superior customer service skills; ability to relate well with all levels of staff and consumers.
- Flexibility
- Incorporates HIPAA, Ohio Law, and 42 CFR Part 2 compliance and training as needed
- Knowledge of OhioMHAS regulations and CARF standards. Perform complex and critical analytical explanations of records/data communicate clear and concise, orally and written
- Ability to work on multiple projects with strict deadlines Establish and maintain effective working relations
- Knowledge of Medicare/Medicaid regulations and guidelines
Organizational Competencies:
- Demonstrates knowledge of the agency's mission, vision, goals, and philosophy as well as the policies and procedures.
- Strives for high client satisfaction by providing leadership and/or assistance to coworkers and clients through the integrated care process.
- Demonstrates consistent professionalism.
- Demonstrates teamwork.
- Abides by the agencies and/or professional code of ethics. Strives to improve own and agency operations.
- Commit to cultivating a non-violent and trauma-informed environment for all employees and clients, through our pursuit of Sanctuary; a trauma-informed model.
- Commits to a deeper exploration of Sanctuary Values.
- Incorporates Sanctuary techniques into daily work activities.
- Participates on Sanctuary process teams and/or supports Sanctuary initiatives
EOE/M/F/D/V/SORequirementsPosition Qualifications:
- Bachelor's degree in social services, business, or related field required a Master's degree is preferred
- Experience with HIPAA compliance and 42 CFR Part 2 knowledge preferred
- Previous experience working with an electronic health record (EHR) system. SmartCare Preferred Experience with Microsoft office products
- High computer proficiency
- Valid driver's license and the ability to be covered under the agency's commercial car insurance.
- Proof of car insurance for the vehicle that will be driven in the course of business.
Physical Requirements:Physical demands described are representative of those that must be routinely met by an employee to successfully perform the essentials duties of this position. Reasonable accommodation may be provided to enable qualified individuals with disabilities to perform the essentials duties.
- Prolonged periods of sitting at a desk and working on a computer, standing, bending, and moving.
- Must be able to lift up to 10 pounds at times.
- Ability to operate a motor vehicle.
Environmental Conditions:Could include Air-conditioned and/or heated office setting, time spent in the field , which could involve driving to various locations in the community.The position may be open to a hybrid schedule after exceptional performance in the probationary period. Those eligible to drive company vehicles must have a valid driver's license and be eligible for coverage as defined by the agency commercial insurance carrier. Those who drive personal vehicles in the course of business must be able to provide proof of insurance.