Quality and Compliance Manager

Description

Summary:

Under the direct supervision of the Chief Executive Officer, the Quality and Compliance Manager is responsible for overseeing HOPE’s quality and compliance program, including the responsibility to oversee and ensure the organizations quality of service and documentation meet the standards as set forth by the Department of Health, AHCCCS, the RBHA, or any governing entities such as health plans. This position works with executive leadership, to develop and implement the corporate compliance program through training, monitoring, auditing, evaluation, investigation, and periodic reporting activities.

Essential Duties and Responsibilities:

• Is HOPE’s Corporate Compliance Manager (see description below)
• Analyzes and evaluates performance improvement data to identify trends in quality of care concerns, member complaints, and grievances.
• Collaborates with programs and other departments to ensure effectiveness of interventions.
• Leads and directs the overall quality improvement activities to achieve quality clinical documentation, compliance with medical record requirements, and member care.
• Prepares and presents reports on a regular basis to clinical leadership that reflects trends, patterns, problems, and opportunities to improve.
• Ensures high risk and unusual events are monitored concurrently and retrospectively.
• Supervises and manages the daily activities of supervisees including: interviewing, hiring, training, professional development, evaluations, and terminations.
• Tracks, trends, and analyzes data from audits to provide actionable solutions to staff.
• Works with the Senior Director of Clinical Services to assist them in developing skills and strategies in staff needed to be successful with their documentation.
• Reviews and tracks incident/accident/death reports.
• Responsible to submit deliverables to funders and maintain or ensure agency reporting requirements are met. Co-chairs the Quality of Care Review Committee.
• Prepares HOPE’s annual Quality Management and Corporate Compliance Plan.
• Prepares a quarterly Quality Management report for the Board of Directors.
• C0-chairs the Corporate Compliance Committee alongside the Senior Director of Clinical Services and presents data for compliance meetings.
• Facilitates trainings based on QI findings and agency needs.
• Can read, comprehend, and actuate state and federal rules and regulations.

Compliance Manager Duties:

• Has the authority to assess records and independently refer suspected Member fraud, provider fraud, waste, and program abuse, and Member abuse cases to health insurance plans and the AHCCCS-OIG.
• Conducts investigations related to grievances, HIPAA violations, fraud, waste, and program abuse, and sexual allegations made by members about staff.
• Creates and maintains Compliance protocols and policies.
• Maintains policies required by the Arizona Department of Health Services (ADHS)
• Has complete access to all information, databases, files, records, and documents in order to conduct audits and to strategically structure the position to independently report suspected fraud, waste, and program abuse directly to health insurance plans and AHCCCS-OIG (42 CFR 455.17)
• Provide training and ongoing education to staff in identifying and reporting fraud, waste and program abuse;
• Oversee internal and external compliance audits;
• Record, track and trend all fraud, waste and program abuse related complaints received including those initiated by health insurance plans or a subcontractor.

Requirements

Qualifications:

• High school diploma or equivalent, plus at least 3 years of direct service experience, preferably in a case management role; or a bachelor’s degree and 2 years direct service experience.
• One to two years of experience auditing and/or monitoring healthcare records relative to data validation and quality improvement.
• 1 year of experience in a behavioral health leadership role preferred.
• Experience using electronic health records.
• Possess the ability to multi-task in a fast paced environment in an organized manner with attention to detail and a high level of accuracy.
• Strong leadership, professional boundaries, and organizational skills.
• Strong knowledge and understanding of ADHS/BMFL regulations, AHCCCS’ Covered Services Guide and ACOM and AMPM manuals, and applicable state and federal laws/statutes governing.
• Strong oral and written communications skills.
• Proven analytical skills.
• Ability to work independently and in a team.
• Ability to work with diverse individuals.
• Must be comfortable identifying as a peer or family member under SAMHSA’s definition. Typically, these skills and knowledge are the result of a combination of practical education in peer support and several years of experience in personal recovery, either directly or as a family member.

Other:

• Working knowledge of state and federal behavioral health programs.
• Interest in and commitment to helping members in crisis from varied social-economic backgrounds.
• Familiarity with a variety of computer software used for researching, tracking, data entry/processing, and reporting information, i.e. Excel.
• Ability to evaluate facts or situations to determine appropriate action.
• Ability to establish and maintain effective working relationships with staff, providers, members, funding sources, and other agencies.
• Ability to maintain confidentiality and comply with HIPAA standards.
• Familiarity with various diverse ethnic and cultural groups.