Quality Assurance and Compliance Specialist

Job Title: Quality Assurance and Compliance Specialist

FLSA Classification: Non-Exempt

Department : MHH

Reports to: Clinical Director

Hours: .6 FTE

Salary: $36.05- $45.67 Hourly

Date Updated: 11.25.24

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Job Description

Summary/Objective
The Quality Assurance and Compliance Specialist is responsible for monitoring, evaluating, and enhancing the quality of services and ensuring compliance with federal, state, and local regulations for The Mental Health HUB. This role collaborates with clinical staff to develop, implement, and maintain quality assurance programs, clinical protocols, and regulatory practices. The Specialist will play a key role in fostering a culture of continuous improvement, safety, and adherence to best practices within The Mental Health Hub.

Essential functions

Reasonable accommodations may be made to enable individuals with disabilities to perform these essential functions.

Quality Assurance:

• Develop, implement, and review quality assurance functions to ensure services align with clinical standards and patient safety guidelines and reporting of quality-assurance studies according to the QA/UR plan.
• Conduct routine audits of clinical documentation, treatment plans, and patient records to ensure compliance with internal policies and external regulations.
• Analyze data and feedback to identify areas of improvement and collaborate with clinical staff to address quality issues.
• Prepare and present quality reports, including metrics and action plans, to Mental Health Hub leadership.
• Lead quality improvement initiatives, setting benchmarks, and driving projects that enhance service delivery and client satisfaction.

Compliance

• Review and maintain familiarity with all grants and contracts.
• Monitors and ensures all billing/invoicing is aligned with all grants and contracts.
• Track and monitor clinical compliance as aligned with grants and contracts

• Monitor EHR system and paper charts for compliance and quality assurance

• Support with obtaining needed permits and licenses needed for mental health hub activities.
• Ensure clinic compliance with HIPAA, OSHA, and other relevant regulatory requirements.
• Maintain an up-to-date knowledge of regulations impacting the Mental Health Hub and proactively address any changes.
• Develop and deliver training sessions on regulatory compliance and quality standards for Mental Health Hub staff.
• Monitor and track licensing and credentialing for clinic staff, ensuring adherence to licensing boards and professional standards.
• Lead investigations into incidents or non-compliance issues, documenting findings and implementing corrective actions.

Documentation and Reporting

• Ensure all clinical and administrative records are accurate, complete, and maintained in accordance with regulatory standards.
• Assist with internal and external audits, acting as the liaison for regulatory bodies and accreditation agencies.
• Regularly update and maintain policies and procedures, aligning them with the latest compliance requirements and best practices.

Training and Support

• Provide guidance and training to clinical staff regarding quality assurance practices, documentation standards, and regulatory updates.
• Serve as a resource for questions and clarification on compliance policies and quality standards.
• Support staff in identifying and mitigating risks, fostering a culture of safety and accountability within the clinic.

Work Environment

• Typical office and clinical environment. Responsibilities may include offsite meetings, training, or other activities as required by business needs.

Qualifications

• Bachelor’s degree in healthcare administration, Psychology, or a related field (Master’s preferred).
• 3 years of experience in quality assurance, compliance, or a related role within a healthcare or behavioral health setting.
• Knowledge of regulatory standards (e.g., HIPAA, OSHA) and quality management frameworks.
• Strong analytical, problem-solving, and organizational skills.
• Excellent interpersonal and communication abilities, with experience in delivering training or presentations.
• Proficiency in data analysis and reporting tools.

Preferred Skills

• Certification in quality management (e.g., CPHQ) or compliance (e.g., CHC).
• Experience in a behavioral health or therapy clinic setting.
• Familiarity with electronic health record (EHR) systems.

Physical Requirements

• This position requires the ability to sit, bend, squat, stoop, and walk-up a flight of stairs and be able to safely lift 50 pounds and carry 20 pounds. Reach with hands and arms and use hands and fingers to handle objects and operate tools, computers, and/or controls.
• Must have a valid Driver’s License and ability to be insured by Company policy.
• Must clear background check for a Community Care Licensed facility, including physical, TB, and drug test.
• Must be 21 years of age or older.

Affirmative Action/EEO Statement
Hanna Center is an equal opportunity employer. All applicants will be considered for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran, or disability status.

Other Duties
This job description is not designed to cover or contain a comprehensive listing of activities, duties, or responsibilities required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.

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