The Quality Improvement Coordinator/Compliance Officer is responsible for the development, implementation, and monitoring of JAMHI’s Compliance Program including conducting investigations, risk analysis, internal reviews and audits, and outcomes monitoring. This position provides guidance and direction regarding local, state and federal rules and regulations and accreditation standards. This position provides guidance and support with staff training and development, and acts as liaison to the accreditation body, CARF International. The position works closely with Senior Leadership and Board of Directors on policy and procedure development, analysis, and implementation.
Oversees JAMHI’s national accreditation status including maintenance of award; acts as agency liaison with CARF International:
- Maintain thorough knowledge of CARF International current accreditation framework and standards.
- Evaluate all elements of JAMHI programs and services within framework of CARF International standards to ensure continued adherence and maintenance of accreditation award.
- Advise Senior Leadership of annual CARF standard updates to ensure organizational compliance.
- Timely completes all necessary paperwork and correspondence required by CARF International.
Provides policy development and analysis to ensure compliance with local, state and federal rules and regulations, and accreditation standards:
- Develop, revise, or update JAMHI Policies and Procedures to ensure compliance with CARF International standards and local, state, and federal rules and regulations including Medicaid.
- Ensure that all JAMHI Policies and Procedures are implemented and adhered to by staff.
Develops, implements, and monitors JAMHI’s quality improvement system through reviews and audits; provides guidance, training, and support in developing solutions to quality concerns including clinical documentation protocol:
- Develop, implement, and monitor JAMHI’s Quality Improvement program to ensure agency compliance with CARF International standards, local, state, and federal rules and regulations including Medicaid; grant requirements, and professional standards for mental health programs.
- In collaboration with Senior Leadership, conduct a risk assessment and recommend changes aimed at reducing risk and vulnerability to fraud, abuse, and waste.
- Direct JAMHI’s internal reviews and audits established to monitor quality and effectiveness of services provided. In coordination with the Clinical Director, provide guidance and support in developing solutions to outcomes of reviews and audits.
- Maintain JAMHI’s Quality Improvement Plan and Outcome Monitoring Report identifying opportunities for effectiveness, access, efficiency and satisfaction.
- Chair JAMHI’s Quality Improvement Committee meetings.
- Collect, track and analyze data, including incident reports, and translate into useful information to assist with quality improvement efforts.
Implements and monitors the Corporate Compliance Program – maintains accounting of compliance concerns, violations, and investigations, provides compliance training, and stays current with local, state, and federal rules and regulations:
- Develop, implement and monitor the Corporate Compliance Program in accordance with local, state and federal rules and regulations, CARF International standards, and other applicable standards.
- Provide quarterly compliance report to Executive Director and Senior Leadership (and annual report to Board of Directors) detailing reports of non-compliance and associated corrective plan.
- Review and update JAMHI’s Corporate Compliance Plan annually as changes occur within the organization, rules and regulations, accreditation standards, or third party payers.
- Develop and coordinate training that focuses on the elements of the Compliance program and seek to ensure that all employees, contractors, Business Associates, volunteers, students, and Board Directors are knowledgeable of, and comply with, pertinent local, state, and federal rules and regulations.
- With assistance of Executive Director, investigate matters related to corporate compliance issues, including employee, client, and/or payor complaints and work to develop appropriate corrective action plan.
- Develop and implement employee feedback loop which encourages employees to report potential problems without fear of retaliation.
- Maintain a library of rules, regulations, standards, agency policies and procedures, and actively seek up-to-date material and releases regarding regulatory compliance.
Provides ongoing training, assistance, guidance, and support to staff in regard to organizational policies and procedures, local, state, and federal rules and regulations, and accreditation standards:
- Develop and coordinate training that focuses on the elements of the compliance program and seeks to ensure that all employees, contractors, volunteers, students, and Board Directors are knowledgeable of, and comply with, pertinent local, state, and federal rules and regulations including Medicaid.
- Provide ongoing training, technical assistance, and problem-solving regarding all compliance standards and concerns, including local, state, and federal rules and regulations including Medicaid, and accreditation standards.
Creates technical reports using SQL and other software tools to extract and analyze data from EHR for organizational reporting and outcomes measurement:
- Build, maintain, and utilize reports in CareLogic EHR to collect and analyze data for JAMHI financial, operational, and clinical systems. Provide information to management and staff for purpose of compliance, program development, and strategic decision making.
- Minimum of a Bachelor’s Degree in behavioral health or related field; Master’s Degree in behavioral health or related field, law, public administration, or business administration preferred.
- Certification in Healthcare Compliance (CHC) preferred, but not required.
- Experience with behavioral health or healthcare organizations preparing for, seeking, and/or maintaining national accreditation preferred.
- Experience with regulatory inspections, audits, site visits from accreditation or other oversight bodies.
- Information Technology experience preferred.
- Must be knowledgeable of standard administrative procedures and have excellent organizational skills with high degree of attention to detail and accuracy.
- Experience writing policies and procedures desired.
- Excellent written and oral communication skills, including computer skill competency.
- Ability to handle multiple projects, work cooperatively with multiple teams and individuals to develop work plans, and time-lined outcomes.
- Ability to pass a criminal background check in accordance with the current state regulation requirements.
- Must have valid Alaska driver’s license with a good driving record and be able to pass the JAMHI auto insurance screening through the independent insurance carrier and/or meet the minimum state liability coverage if using own personal vehicle.
Please complete a JAMHI application: http://www.jamhi.org/images/clientid_218/employment.pdf at the bottom of the job page. You can use one of three options to submit your resume and application (both resume and application are required):
- Email address at firstname.lastname@example.org or
- Submit your application and resume via email or
- Fax to 907-463-6858.
Additional Required Information: If you are selected, please provide the following at the time of the interview:
1. The names and current contact information of three (3) professional references
2. An official college transcript.
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