Manager of Compliance and Quality Assurance

Job Title: Manager of Compliance and Quality Assurance

Department: Compliance

Reports to: Chief Operating Officer/Chief Compliance Officer

Job Type: Full Time, Salaried, Exempt

Job Location: Chicago and surrounding communities

Salary Range: $55,000 to $65,000 competitive salary, commensurate with years of related experience, skills, education and training.

Rincon - Building Spaces, Restoring Communities- Who we are:

What began as a small clinic established by young community leaders on the West Side of Chicago in 1972 has grown into one of the largest providers of high-quality and culturally competent services focusing on counseling and crisis intervention services, substance use prevention and treatment, violence prevention, education, case management, community and family services. We are dedicated to rendering compassionate and effective programs to promote the quality of life by catalyzing to advocate, educate and empower individuals and their families.

Position Description – What the Role Entails:

The Manager of Compliance and Quality Assurance will be responsible for driving behavioral health quality assurance and ensuring that our organizational policies, practices, and operations adhere to all applicable standards, regulations, and laws. Reporting to the Chief Compliance Officer, you will be assisting them in implementing a robust organization wide compliance program designed to prevent, monitor, identify, and respond to incidences of non-compliance. You will be responsible for designing, implementing, and monitoring clinical quality assurance initiatives and activities that promote continuous improvement and meet all regulatory and accreditation requirements. The Manager of Compliance and Quality Assurance will collaborate with clinical and administrative leadership to develop strategies that improve client outcomes, service delivery, and operational efficiency.You will also assist staff across the organization to understand, implement, and follow all regulatory, ethical, licensing, accreditation, quality, and proper conduct standards. In this role, you will be reporting to the executive team on overall quality improvement and compliance efforts, including audits, accreditation/licensing reviews, and risk assessment.

Company Culture - Do Our Values Speak to You?

At Rincon, our commitment to mutual respect, inclusivity, and diversity is woven into the structure of all that we do. We value:

• Dedication- Embodying effective and transparent leadership and quality client care.
• Education – Preventative programming and clinical services based on industry standards, competence and outreach.
• Accountability – Consistent service delivery, measurable success, and sensible financial management.
• Advocacy – Empowerment, reduction of treatment stigma, and relationship building with partners.
• Compassion – Embracing culturally diverse communities and equality through sensitivity to individual needs.

With these values in mind, we promote a culture that fosters professional development and agency success. Many of our employees span an extended tenure, and we pride ourselves on developing dedicated and supported team members.

Areas of Accountability - What you will be doing:

Fostering a Culture of Compliance and Quality Assurance

• Assist in fostering a culture of compliance and continuous quality improvement by ensuring that Rincon and its affiliates adhere to all applicable regulatory requirements, including governing body, ethical, licensure, accreditation, best practice, and proper conduct standards.
• Develop, implement, and manage a comprehensive quality assurance framework that promotes best practices in behavioral health care, improves client outcomes, and optimizes service delivery.
• Help design, implement, and improve systems, processes, policies and procedures to integrate compliance, quality assurance, continuous improvement, and accountability in daily operations.

Policy and Training

• Develop and update compliance and QA related policies and procedures as needed to meet/exceed relevant standards and regulatory requirements. Maintain an updated inventory of organizational policies and procedures.
• Drive knowledge development across the organization to stay current with evolving regulatory requirements and industry best practices, tools, techniques, and performance standards.
• Provide coaching and training to staff across the organization to improve understanding and consistency in compliance, quality assurance and continuous improvement, lead compliance and QA workgroups and committees as needed. Periodically assess the knowledge needs of staff and develop plans to address improvement.
• Assist in the production and update of staff resource materials including reference guides, matrices, charts, checklists, and workflows.

Audits, Risk Management and Monitoring

• Coordinate external audits and support Clinical Directors and their teams in preparing for and achieving successful external audits, clinical accreditation and licensing reviews (e.g. CARF, DMH, SUPR).
• Develop and manage internal compliance, quality monitoring and continuous improvement initiatives to ensure services are meeting service standards, projected targets, contractual and regulatory requirements.
• Identify risks, including data privacy requirements, based on organizational incidents, audits, program reviews, reporting and other monitoring tools. Implement risk management strategies to mitigate potential liabilities.
• Manage the organization’s incident reporting system, investigating incidents and ensuring timely reporting and resolution.
• Develop and implement corrective actions and track the effectiveness of remediation efforts.
• Maintain accurate documentation, prepare and present data driven compliance and QA reports to organizational leadership. Utilize metrics to identify areas of improvement and track the success of compliance and quality improvement initiatives.

All other duties as assigned

The Knowledge and Expertise that Matters Most - What you bring to the Role:

• Demonstrable knowledge and competency in behavioral services and relevant regulatory, accreditation, legal, and ethical policies and practice standards, including CARF, HIPAA, etc.
• Highly skilled at coordination and organization of processes, workflows, and data.
• Ability to quickly understand, adapt and relay new regulations across the organization.
• Skilled at working collaboratively with program teams, supervisors, and executive leadership.
• Commitment to the values of the organization while demonstrating confidentiality, discretion, accountability, good judgment, flexibility and patience.
• Knowledge, competence, and commitment to the principles of trauma-informed, culturally competent, and recovery-oriented care.
• Strong conflict resolution, problem-solving and investigation skills.
• Detailed oriented, highly organized, works efficiently and with accuracy.
• Effective, efficient communication, verbally and in writing.

Position Qualifications – What is required to Perform the Role:

• Master’s degree in Social Work, Health Care Administration, Public Health, Behavioral Health, or a related field required. Clinical background and licensing (e.g., LCSW, LCPC, or similar) is required.
• Minimum 1-3 years of behavioral health compliance experience required; experience with HIPAA, SUPR, DMH, IDoA, DCFS and CARF preferred.
• Pass a pre-employment TB Test, and various background checks, including clearance by the DHS Background Check Unit, DCFS Background check and the Healthcare Workers Registry.
• Vehicle/License/Insurance and ability to drive to any of our offices or those of our affiliates, currently throughout Chicagoland, Cicero, Berwyn and Kankakee areas.
• Proficiency in Microsoft 365 (including Outlook, Excel, Word, PowerPoint, Forms and Teams), Adobe Pro and familiarity with or ability to learn SAMMS, CIS and other EHRs.
• Adhere to agency’s non-discrimination policies.

Rincon Rewards & Benefits- How we value you:

• Health insurance
• Dental & Vision insurance
• Life insurance
• Employer sponsored Short- and Long-Term Disability Insurance
• 403(b) Retirement Plan
• Generous PTO (Paid time off)- Accrue up to 21 days in Year 1, generous PTO carryover.
• Employee Assistance Program
• Professional Development Opportunities
• Employment may qualify for the Public Service Loan Forgiveness Program (PSLF)
• Chicago employees may qualify for pre-tax Chicago Transit benefits

Rincon’s Work Environment – What to expect:

• High level of interaction with program staff.
• Physical ability to bend, squat, kneel, twist, reach, pull, and lift normal items (10-20lb).
• Travel required to all of Rincon’s existing and future geographic service areas, currently Cook and Kankakee Counties.
• May be expected to work outside normal office hours.

Schedule:

• Variable, 8hr day, 1hr unpaid lunch
• Monday to Friday, some evenings/weekends

Language:

• Bilingual English/Spanish Preferred

Application Process:

• Please follow website instructions.

RINCON FAMILY SERVICES IS AN EQUAL OPPORTUNITY EMPLOYER

Position Qualifications – What is required to Perform the Role:

• Master’s degree in Social Work, Health Care Administration, Public Health, Behavioral Health, or a related field required. Clinical background and licensing (e.g., LCSW, LCPC, or similar) is required.
• Minimum 1-3 years of behavioral health compliance experience required; experience with HIPAA, SUPR, DMH, IDoA, DCFS and CARF preferred.
• Pass a pre-employment TB Test, and various background checks, including clearance by the DHS Background Check Unit, DCFS Background check and the Healthcare Workers Registry.
• Vehicle/License/Insurance and ability to drive to any of our offices or those of our affiliates, currently throughout Chicagoland, Cicero, Berwyn and Kankakee areas.
• Proficiency in Microsoft 365 (including Outlook, Excel, Word, PowerPoint, Forms and Teams), Adobe Pro and familiarity with or ability to learn SAMMS, CIS and other EHRs.
• Adhere to agency’s non-discrimination policies.
• Knowledge, competence, and commitment to the principles of trauma-informed, culturally competent, and recovery-oriented care.